Insurance Information

Our office is out of network with all insurance companies so we have no contract or agreement with your insurance company but, as the policyholder, you do. We encourage you to call your dental insurer and request their out of network fee schedule be emailed or mailed to you. We will file primary and secondary dental insurance claims with PPO insurance plans as a courtesy to our patients. We can not file any claims with HMO or state insurance like Meridian, All Kids or Medicaid. It is essential that you provide current and accurate insurance information so that we may file your claim properly. Failure to do so can result in the claim being denied by insurance and you having to pay 100% of the treatment cost. 

Because we are not in their networks, the insurance companies will not share their reimbursement fee schedules with us but they must share them with you when requested. Our doctors treatment plans are based on your child’s dental needs to achieve the best overall outcome, not what an insurance actuary specifies. The parent/responsible party is responsible for payment of all treatment costs not covered by or denied by insurance. For larger treatment plans and those requiring General Anesthesia we can submit a pre-determination to your insurer to see what procedures they will cover and at what percentage before beginning treatment. A Pre-D takes 2-4 weeks for an insurer to complete and return to our office.

Important Dental Insurance Facts

Fact 1– No dental insurance pays 100% of all procedures, it is meant to be an aid to offset some of the cost of receiving dental care. Many consumers think that their dental insurance pays  100% of all dental fees and this is not true. Most plans pay between 50% to 80% of the average total fee, minus your per patient deductibles (usually $50-100/yr). Some pay even less, very few pay more. The coverage amount is determined by your insurance co.’s fee schedule which is determined by the plan that has been negotiated between the employer and the insurance company. The simple rule is lower cost insurance plans pay less in benefits and cover fewer procedures.  

Fact 2– Benefits are not determined by our office: You may notice that your dental insurer reimburses you a lower rate than the dentist’s actual fee. Frequently, insurance companies state that the payment was reduced because your dentist’s fee exceeded the usual, customary and reasonable (UCR) fee used by the insurance company. A statement like this gives the impression that any fee higher than their “allowed fee” is unusual, not customary and unreasonable for a certain service. This wording is misleading and inaccurate. Insurance companies set their own reimbursement fee schedules and each company uses different information to determine their reimbursement fees. Insurers are very slow to update their reimbursement fee schedules to account for things like CPI inflation, wages and materials price increases. Insurance companies will go several years without ever increasing their reimbursement fees (i.e. their payout for procedures). However, these same insurers are very quick to increase the insurance premiums you pay them claiming things like CPI inflation and wage increases. As a result, the Insurance company has very low claim payout amounts based on old, outdated fee info but they have promptly increased the premiums you pay them. Through their wording, insurance companies imply that your dentist’s fees are unreasonable rather than disclosing that their reimbursement rates for dental procedures are stale, outdated and most likely well below the current marketplace.

Fact 3– Deductibles & Co-Pays matter: When understanding dental benefits, deductibles and co-pay percentages must be considered. To illustrate, assume the fee for a procedure is $150.00. Assuming that the insurance company allows $150.00 as its UCR fee and cover at 80%, you can calculate the benefit that you will be reimbursed. First a deductible, usually $50.00, will be subtracted, leaving a $100.00. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of the $100.00, or $80.00 leaving you to pay the deductible ($50) plus the 20% not covered ($20) totaling $70.00. Now, if the UCR is $100 for that same $150 procedure and your plan pays 80% and your deductible has not been paid then your insurance reimbursement will be $30 leaving you to pay $120. Most importantly, please keep our office informed of any insurance changes such as insurance company change, employer changes, Member ID or Group number changes. Failure to do so can result in a denied claim and you having to pay 100% of the bill.

Fact 4 – Embedded Dental Policy and High Deductible policies; Buyer Beware!!! If your dental policy is embedded within your medical policy or you’ve chosen a high-deductible policy you will most likely have to pay significant out of pocket amounts ($2000, $3000, $5,000 or more) to meet your medical deductible BEFORE your dental coverage benefits kick in. These plans trick you with a low monthly premium payment but wind up being extremely expensive when treatment is needed.  As the insurance holder, you are responsible for knowing if you have a high deductible or embedded policy, not our office.

American Dental Association files class-action lawsuit against Delta Dental

Nov 2019; The American Dental Association (ADA) has filed a class-action lawsuit against Delta Dental plans and the Delta Dental Plans Association. The complaint alleges that Delta Dental has engaged in anticompetitive conduct and violated federal antitrust laws by allocating territories of operation and dividing the U.S. market in order to restrict competition and reduce reimbursement rates to dentists. The complaint goes on to allege that Delta Dental’s anticompetitive acts hurt both dentists and their patients by limiting the choices of dental care available to patients and making it more difficult for dentists to deliver the care that patients need and want.

In addition to the ADA’s complaint, individual dentists have filed several class-action complaints against Delta Dental, also alleging antitrust violations. In these complaints, the ADA and the individual dentists are requesting that the court certify the proceedings as a class action. The court will rule on that request in the coming months.

The earliest this case potentially could proceed to trial is now sometime in late 2025. The case has now been pending for more than three years, but is still in its relatively early stages, said the ADA’s Division of Legal Affairs.

 

California Dental Association cleared to sue Delta Dental of California

A judge has ruled that the California Dental Association and individual dentist-plaintiffs could continue to pursue their claims against Delta Dental of California. The CDA claims that Delta Dental of California violated the implied covenant of good faith and fair dealing when adopting the 2023 contractual amendments, according to an Oct. 19 news release from the CDA.

The legal action was filed by the CDA in late December 2022 and claimed that Delta Dental of California was not meeting its obligations to dental providers. Delta Dental of California and the individual defendants filed motions to dismiss the claims. The court granted some of Delta Dental of California’s motions but also allowed CDA to modify their complaints to include more facts and information for consideration.

The CDA intends to pursue as many actionable claims against Delta Dental of California as possible, the release said.

Federal judge will not let Delta Dental end a massive antitrust class action suit

CHICAGO — A federal judge won’t let Delta Dental end a massive antitrust class action accusing the dental care insurer of forcing dentists to ink agreements that allegedly unfairly suppress their payments.

In an opinion issued Sept. 4, 2020 U.S. District Judge Elaine Bucklo denied a motion to dismiss a lawsuit consolidated from complaints brought primarily by dentists across the country.

Named defendants include the Delta Dental Plan Association, affiliated national entities Delta Dental Insurance Company, DeltaCare USA and Delta USA Inc., 39 independent Delta Dental companies operating in all 50 states and Puerto Rico, as well as Dentegra Group and Renaissance Health Service Corporation, which fully or partially own several of the 39 state plans.

The Chicago-based American Dental Association joined the litigation last November, alleging Delta’s agreement makes dentists abide by noncompetitive geographic areas, which paves the way for the companies to share pricing information to establish the lowest acceptable rates. Because Delta dominates the market, the dentists say they have no choice but to accept the contract. They also said Delta limits the amount of work the state insurers may conduct outside of Delta-branded business.

“Plaintiffs acknowledge that defendants’ below-market reimbursement rates could, theoretically, translate to savings in the premiums paid by their policyholders,” Bucklo wrote. “But they assert that rather than passing on any savings to consumers of dental products and services, defendants have paid lavish salaries to their executives and bloated their capital reserves.”

Judge Bucklo rejected Delta’s argument it should be treated like credit card companies, which “operate two-sided transaction platforms” servicing both a merchant and customer simultaneously and have been allowed to use similar territorial restrictions. Rather than being transaction based, Bucklo said, dental insurance customers typically pay fixed premiums that aren’t directly linked to the actual costs of their office visits.

She further said the dispute concerning the effect of reimbursement rates on customer premiums, balanced against plaintiffs’ allegations concerning Delta executive compensation and cash reserves, can’t be resolved through a motion to dismiss.

While Delta didn’t dispute allegations that price fixing or output limitations are anticompetitive, it argued the facts laid out in the complaint don’t show how the policies are illegal.

Bucklo disagreed, writing the plaintiffs didn’t “merely incant the words ‘price fixing’ and ‘revenue restrictions’ without including substantial details to support their claims.”

The complaint, Bucklo noted, “describes how (the Delta Dental companies) obtain and share pricing information, agree collectively upon below-market reimbursement rates, then police payment of those rates to ensure uniformity in practice. These allegations give substance to the label ‘price fixing’ and are sufficient to inform defendants of the nature of plaintiffs’ claim.”

Bucklo also rejected arguments the plaintiffs didn’t demonstrate an ill effect on the entire dental insurance market, restating her position that “no judgment can be made at this stage regarding the significance of any indirect network effects, which may or may not require a two-sided market analysis.”

Although she agreed the plaintiffs’ description of the insurance market was “not a model of clarity,” Bucklo wrote it ultimately was sufficiently “consistent with their theory that defendants have combined to form a buyers’ cartel with monopsony power that makes it difficult for alternative buyers to compete, thereby depressing the market price for the sale of dental goods and services.”