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Delta Dental Reports on Updates

Delta Dental Reports on Updates
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There has been some confusion over the CMS delay in the Medicare provider enrollment deadline and the regulations set by Delta Dental for its providers. Dr. Jeffrey Johnston, Delta Dental VP and Chief Science Officer, recently visited with the IDA Council on Dental Benefit Programs and provided the following answers to the Council’s inquiries: 

  1. If you contract with Delta Dental as a Premier Provider now, you will be reimbursed at a lower level than providers who contracted prior to August 1, 2014.
    • Delta is doing this because they are losing market share when trying to sell Premier Plans vs a PPO Plans to employers in the state.
    • If you are an office that was contracted with Delta Premier prior to August 1, 2014 and you hire or sell to a non-contracted dentist, the new dentist will be contracted with Delta Premier at the lower remuneration rate.
    • If a fax back from Delta shows different coverage and/or annual maximum when a patient receives treatment at a PPO vs Premier/Out of Network Office, that dental plan is being administered by Delta on behalf of a self-insured employer versus a fully insured plan sold by Delta. Discussions with the patient’s employer can help to better understand those differences.

 

  1. Medicare Opt In/Out with regards to Delta Dental:
    • If a provider opts out of Medicare after June 20, 2016, the provider will be removed from all Delta networks.
    • If the provider has opted out prior to June 20, 2016, Delta is allowing a 2 year waiver and at the end of the waiver you must choose another option other than opt out to remain in Delta network.
    • If providers chooses to do nothing, they will still be in Delta Dental networks at their current fee schedule and their Medicare Advantage claims will still be paid.
    • The only consequence of doing nothing is that after January 1, 2019, pharmacies will not be reimbursed for prescriptions providers write for their Medicare patients.
    • The one thing providers should not do is opt out if they want to protect their current status both with Delta Dental and Medicare.

 

  1. Focused Review:
    • The codes and procedures for focused review are very clearly outlined in the correspondence that all dentists on Focused Review receive.
    • Early in the process, Delta will not tell the dentist why they are on review (Targeted vs Random).
    • Being on Focus review does not necessarily mean the dentist is doing anything wrong. Many dentists are merely randomly selected.
    • Any dentist (in network or out of network) that submits claims to Delta may be chosen to participate in a focus review

 

  1. How is ADA code D4346 being treated?
    • Delta will remunerate this code at the fee they would remunerate a D1110.
    • It does count as one of the patient’s annual cleanings.
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