Innovations in the Dental Insurance World

 

Medical insurance has been using tiered systems to provide care to patients for some time. A tiered system categorizes physicians by quality and cost efficiency standards. While the patient chooses their provider, the patient's copay may vary based upon the provider tier that is chosen. Insurance companies can reimburse different tiers on different fee schedules potentially allowing network providers with better outcomes higher reimbursements. An example of medical insurance tiered system: TIER 1 Providers meet excellent quality and/or cost efficiency standards Members pay the lowest copayment TIER 2 Providers meet good quality and/or cost efficiency standards Members pay the mid-level copayment TIER 3 Providers who are outside the insurance network Members pay the highest copayment As you know, trends in dentistry typically follow trends in medicine. While the tiered provider system is not yet here for dentistry, the concept of evaluating the quality of dental care has been on the horizon for some time, and will shortly be utilized by major dental insurers. How will this work? A leader in this type of data analytics is P&R Dental Strategies. They have developed a unique, objective, quality measurement program for dentists. Their methodology, called DentaQual, leverages a nationwide, multi-payer dental claims database (DentaBase) to measure quality by analyzing cross-payer claims and dentist utilization data. Quality is measured based on metrics scored in each of 5 categories.

The DentaQual score for a dentist is based upon an individual dentist's "standard deviation from the norm", the norm being the average practice behavior of a dentist's peers in a geographic area. It is not based upon predetermined or subjective benchmarks such as user reviews. As the largest dental insurer in Arizona, Delta Dental of AZ, will soon make these quality scores available to patients to help them in selection of their dentist. Other insurers such as United Healthcare and other Delta Dentals have already incorporated this platform and it's probable that other insurers will follow suit. In order to better understand the purpose behind these metrics and how insurance companies will be using them, we have invited Mr. Mike Jones, President and CEO of Delta Dental of Arizona to participate in our upcoming seminar. Mr. Jones will provide us with an update of current and future initiatives and explain how Delta Dental will be leveraging these new metrics. We have also invited Mr. Michael Urbach, President of New Markets for P&R Dental Strategies to come and explain how DentaQual works and what affect they expect to have on the dental insurance marketplace. We look forward to their presentation on Tues, March 22, 2022 at 6:00pm at Superstition Springs Endodontics.

Insurance Companies Respond to Delta Dental of AZ's Recent Changes

The dental insurance world in AZ is a buzz with the recent changes regarding Delta Dental of AZ.  These changes will force providers into the PPO network, to become exclusive Delta providers or terminate their relationship with Delta Dental of AZ.


There has been contact made with the AZ Attorney General's office regarding these concerns by other dental insurance providers.


Here are a few of the recent letters we have seen regarding their response to Delta. While being an exclusive provider for Delta is not a new concept, it is obvious that other insurance companies see that as anticompetitive and questioning it's legality.

Delta Dental of Arizona Cutting Reimbursements to Arizona Dentists

The Delta Dental of AZ website says, "...dentists are valuable partners in providing quality oral health care and Delta Dental is striving to find the right balance between the dentists, the companies and our enrollees to remain the leading dental benefits provider in our state."  The latest move in striving to find this balance is to reduce the reimbursements to Premier Provider dentists by forcing them into the lower paying PPO dental plan.  In a recent letter from Delta Dental of AZ, I was informed that the Premier Plan, of which I am a provider, is being retired and I have three options:

1. Accept the Delta Dental PPO contract fees
2. Become an exclusive provider - accepting ONLY Delta Dental insurance
3. Terminate my provider relationship with Delta Dental

In order to evaluate the decision of staying with Delta Dental, I decided to look to FairHealthConsumer.org to find out what a "fair" price is for endodontic procedures in my region.

Fair Health is a national, independent, not-for-profit corporation whose mission is to bring transparency to healthcare costs and health insurance information through comprehensive data products and consumer resources. FAIR Health uses its database of billions of billed medical and dental services to power a free website that enables consumers to estimate and plan their medical and dental expenditures.

As a consumer, this is what FAIR health says should be charged for endodontic treatment in my zip code.  If I have no insurance, this is what I should expect to pay.

According to FAIR health, the reasonable cost for a molar root canal in 85206 zip code is $1203.00

According to FAIR health, a typical dental insurance policy should expect the insurance to cover $601.50 of the root canal and I should expect an out of pocket expense of $601.50.

Now looking at the proposed reimbursement for an endodontist doing these three procedures, Delta Dental PPO wants me to reimburse at the following rates.

Molar RCT (D3330) 36% below the FAIR price

Bicuspid RCT (D3320) 41% below the FAIR price

Anterior RCT (D3310) 44% below the FAIR price

At SSE our current fees are BELOW the FAIR health fees for our area.

As a Premier provider with Delta Dental we are reimbursed at:

Molar RCT (D3330) 16% below the SSE Fee

Bicuspid RCT (D3320) 23% below the SSE Fee

Anterior RCT (D3310) 30% below the SSE Fee
If we become a PPO provider for Delta Dental, we will be reimbursed at:

Molar RCT (D3330) 31% below the SSE Fee

Bicuspid RCT (D3320) 42% below the SSE Fee

Anterior RCT (D3310) 48% below the SSE Fee
Looking at those reimbursements, Delta Dental PPO would become the worst reimbursing insurance company that we work with. As a business owner, at what point does it become non-profitable to see Delta patients? How does any business function at a 30-50% discount?  The obvious business answer is that you have to make it up the difference in volume which typically means a decrease in the quality of service.  (does corporate dentistry sound familiar?)

If you are a Premier provider, you may want to look at the numbers carefully.  If you don't contact Delta by written notice, you will automatically become a PPO provider on July 1, 2014!

If you are a general dentist, the Delta PPO want to reimburse you at the following rates:

Molar RCT (D3330) 54% of the FAIR price

Bicuspid RCT (D3320) 52% of the FAIR price

Anterior RCT (D3310) 51% of the FAIR price

As a company, who was initially founded by dentists in California, Washington and Oregon and has become one of the largest dental networks in the country, this move to cut reimbursements by forcing its premier providers into the PPO network does not seem to support the dentist.


If you are a dentist in another state that has been affected by Delta Dental cuts, what has been your experience?

If you are an Arizona dentist, what are you planning to do and how do you think it will affect your practice?

Some other interesting links regarding this pattern of Delta Dental to cut reimbursements to Dentists.

DentalTown Discussion regarding Delta Dental of Washington cutting reimbursements

Dental Warrior Blog reporting Delta Dental of Idaho cutting reimbursements

Delta Dental of Missouri cuts reimbursements

Dental Economics: Things to consider when dropping a PPO

FAIR Health Consumer Cost Lookup

FAIR Health is an independent, not-for-profit organization that was established to maintain a database to help insurers and consumers determine reimbursement rates for out-of-network charges, and provide patients with a clear, unbiased explanation of the reimbursement process. This first-of-its-kind database will allow consumer to get cost estimates for medical and dental procedures in their geographic area. The database will also help consumer estimate how much their insurer will reimburse for procedures performed "out of network". This website should help patients to clear the cloak of secrecy around the "out of network" reimbursements that the insurance companies work so hard to maintain.

If you think the insurance companies set this up to help consumers understand the insurance process, then think again. This is part of the large settlement following a 2009 investigation by New York State Attorney General Andrew Cuomo that discovered a conflict of interest between the Ingenix database, which was used by insurers nationwide to set reimbursement rates for "out of network" health services. Ingenix happened to be a subsidiary of UnitedHealth, the second largest insurer in the nation. It was determined that Ingenix had a vested interest in helping set rates low so companies could underpay patients for "out of network" services.

You can check out the website, and encourage your patients to use it too!

http://www.fairhealthconsumer.org/