Understand Its Limits
Delta Dental is a dental insurance company that was started by a panel of dentists. Originally they wanted to provide dental insurance that would preserve the quality of dental care in the best interests of the patient. However, they were hit with the realities of the marketplace, and in order to continue to thrive as a dental insurance company, they felt great pressure to control costs.
Delta Dental was the first dental insurance plan to be based on a membership contract with dentists. This gave them certain power to dictate treatment. If a dentist wanted to be a member of the plan, he or she needed to agree to whatever restrictions Delta Dental imposed. At first these restrictions were very reasonable, but with the increased cost containment pressure from Delta Dental, they became less reasonable.
In the early days of Delta Dental, they created a formula for the fee levels that they would expect, based on statistical data gathered from participating dental offices. They compiled a fee list of what were called “reasonable and customary” fees, and as long as a dentist’s fees fell within that range, they would accept that fee. With increased financial pressure, they felt they had to set their own fee structure and not base it on a survey. They continued to use the term “reasonable and customary” fee, but removed any linkage to what fees were actually being charged by participating dentists. I know that at least in Iowa, where I was a participating dentist with Delta Dental, they were not truthful but continued to claim, in their contracts with dentists, that their fees were based on a percentile of the fees actually charged when they weren’t.
To add to this, they have tried to assert some more superiority, taking an accusatory tone toward participating dental offices that resisted their restrictions, and not owning up to their own financial motivations.
For these reasons, many high-quality dentists have decided not to participate with Delta Dental. If you have Delta Dental insurance and you go to a non-participating dentist, you will still receive benefits. But you will have to pay the dentist for their full fee, and then Delta Dental will reimburse you at their level of benefits.
Be aware also that Delta Dental is administered by state associations, and their policies and how they are administered will vary from state to state.
—Dr. David Hall.
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