Carol Tekavec, RDH
Delta plans throughout the nation have been undergoing a period of serious change. Originally, Delta plans were financial-benefit programs started by dentists for the benefit of both patients and dentists. In many states, Delta Corporations were (and some still are) nonprofit. The hallmark of a Delta plan used to be an emphasis on fee-for-service dentistry, albeit "filed fees" submitted by participating dentists.
In many states, the "filed fees" format is being replaced with a Maximum Plan Allowance (MPA). The MPA is defined by Delta as a set maximum payable fee, based on total fees submitted by Delta participating dentists within certain regions. The MPA per procedure for a particular region is not available to either dentists or their patients. The only way to know what the Delta payment toward a procedure will be is by submitting a claim and seeing what is paid. Eventually, by keeping track of claims, a dentist will uncover the payment mystery.
When "filed-fees" stipulated what the dentist's fee was — and subsequently what portion (50 percent, 80 percent) Delta paid of the total fee — the dentist then would "balance bill" the patient for the remaining portion of the fee up to the amount of the filed fee.
With the MPA system, the patient copayment is the balance of what is left up to the MPA only. For example, let's say a dentist's fee is $800 for a crown. The MPA for the region turns out to be $600. The Delta plan pays 50 percent of the MPA of $600 or $300. The dentist may only balance-bill the patient $300.
"Disallowed" procedures under an MPA Delta plan are still disallowed and not billable to the patient. An example of this type of situation would be a multi-surface anterior composite which may only be billed to Delta as a single surface composite. Billing for any additional surfaces is "disallowed."
Attachments, radiographs, and narratives are being phased out and no longer need to be sent with many claims, as long as an office does not send in claims for more than the "average" number of services. Offices "overutilizing" certain codes will trigger a Delta review, at which time they will be required to provide the attachments for a particular period of time.
If problems are seen within this time frame, Delta may perform a physical audit of the patient records, (a "privacy and HIPAA" permitted function as per the dentist's contract and the subscribing patient's contract).
With these major changes in mind, here are some factors to keep in mind when dealing with Delta:
* Delta is trying to standardize computer systems throughout each state and, in some cases, in multiple states. Tracking "filed fees" and attachments is no longer cost-effective for the company.
* More and more employers are resisting purchasing "filed-fee" benefits plans for their employees because of the cost of the premiums. Preferred-provider style plans are typically much less expensive. Even though the MPA system is not exactly a PPO, it comes close.
* Since PPO fee schedules are available to PPO providers, why is fee information unavailable for the Maximum Plan Allowance? The reason given by Delta is the need to stay competitive with other benefits plans. According to Delta, if every dentist charged the MPA for each service, the plan could not survive. Delta relies on a certain number of dentists to charge less than the MPA.
* As with other plans, dentists who do not want to accept an MPA fee may drop out of the network. Delta still will provide a benefit for patients who see nonparticipating providers, and the payment will be sent directly to the patient. The benefit for the patient seeing nonparticipating dentists is said to be in the 50th percentile of fees for a particular general geographic area.
* Dentists and dental insurers are facing an interdependent fight for survival. Patients throughout the nation have been faced with wide spread job layoffs. Those retaining their jobs have seen their medical premiums skyrocket. Dental benefits continue to be important to employees; however, medical benefits still typically take precedence.
Carol Tekavec, RDH, is the author of the Dental Insurance Coding Handbook Update CDT-4, co-designer of a dental chart and an informed consent booklet, and a national lecturer. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com.