I wrote on this subject last fall but it seems that some of our clients, believing perhaps that they were bulletproof, chose to ignore my recommendation to confirm their Delta Dental Insurance status.
In that article, I wrote that a number of our clients and other doctors had been receiving letters from Delta, from Blue Cross, and from other PPO companies, demanding that huge refunds be made to patients because for quite some time (sometimes for many years!) the doctor had been charging patients more than their approved PPO fee. The refunds necessary in these cases ranged from a low of $40,000 to a high of well over $100,000!
This situation occurs primarily with Delta Premier. Many doctors seem to believe they are not participating members of Delta, even though 15 years ago they signed a contract that they no longer remember. Many doctors, especially doctors in California, Oregon, and Washington, believe that Delta Premier is not a PPO and that they do not have to submit their fee schedules and that they are free to charge what they wish. That is simply not the case. Delta Premier is absolutely a PPO!! Read your contract and you will learn that Delta Premier has the power to limit your fee to Delta patients to basically anything Delta wants your fee to be. Because for many years, the Delta approved fees were above what most doctors charged, doctors forgot what their contract said and continued to raise their fees over the years, often without submitting those fees to Delta for their approval. Over time, many doctors “forgot” that they had at one time signed a participating agreement with Delta.
Over the past couple of years quite a number of doctors have been rudely awakened by having received the letter I described earlier. In the most recent two weeks, two more clients have received that letter. On the most significant of the two cases, the doctor had not submitted fees to Delta for more than 8 years. In all of that time the doctor had continued to charge their full case fee to all Delta patients. Now, 8 years later, when the doctor’s case fee on a full orthodontic adolescent start is $5,980, Delta informs him that his approved fee is only $5,280 – what he had been charging in 2006. He owes a substantial refund, up to $700 on many hundreds of patients, to every full fee Delta patient that he has started since 2006. Fortunately in this case Delta agreed to update the fee schedule to what it was a year ago so refunds are only due to the patients who have started during the most recent 12 month period.
The PPO problem continues… Delta of the NE, including Maine, New Hampshire, and Vermont, announced just a week ago that participating doctors no longer need to submit their fees for Delta approval. This particular Delta group has implemented a “standardized” fee schedule to be applied to all doctors in the region. Still think Delta Premier is not a PPO? If you do, go to the California Dental Association website and read about what California Dental Service (Delta) has planned for California Dentists and Orthodontists.
So, if you believe you are not a Premier member, go onto the Delta website and check the provider list. If your name is on that list, you are a participating doctor in the PPO and you are subject to the Delta fee restrictions in place in your particular state. Even if you know that you are a Premier provider, be certain your most current fee structure has been “approved” by Delta. You do not want to get one of those $100k letters!
The best bet is to get off of any PPO’s you participate with before the ACA related changes in dental and orthodontic insurance cause declines in the numbers of insured patients that will, over the short term, trash the productivity and the profitability of your practice.
