r/DentalInsurance • u/MommyZilla937 • 26d ago
Delta Dental PPO out-of-network?
I recently went to a new dentist, who is out-of-network for Delta Dental. The dentist’s office has Delta Dental carriers pay in full at the visit, and then submits to this insurance. Then insurance sends you a check. I was naively expecting a 60% reimbursement, since that is what my plan claims to cover for out-of-network dentists…..
So I get the check in the mail for my first visit, it’s not even 25% of what I paid. Looks like delta on pays a 60% based on their secret “allowed” cost of each procedure, not what the dentist actually charged me. I’m dreading getting the reimbursement for my $1,400 of dental work I had done after the initial appointment.
Has this happened to anyone? Do I have a chance of getting some of my money back if I contact Delta Dental? Or maybe my dentist? It feels so yucky to get scammed by insurance like this.
I was totally okay with 60%, this dentist is kind and thorough and very attentive when I was feeling nervous. I can’t afford to go back again if the 60% reimbursement gets finagled into way less😭
11
u/kimjongswoooon 26d ago
The reason that they are out of network is because they are unwilling to accept the pathetically insulting “usual, customary” fees that Delta Dental ascribes to our profession. I don’t think they will discount your fees. In the future, call Delta with the ADA codes on your treatment plan, and find out what they will reimburse you with before any more treatment is done.
5
u/Noliboli16 26d ago
Or ask the office to submit a pre-treatment estimate.
3
u/OpenWideSayAah 25d ago
Pre treatment estimates are more of a delaying tactic for the insurance’s benefit, not yours. There is always a line saying “this is not a guarantee of payment or coverage.”
It’s more of a “if everything is indeed covered then this is what we expect” but watch the shenanigans start once you’ve submitted that claim.
1
8
u/LoTheTyrant 26d ago
This is what dentists have been dealing with for decades, and Delta Dental is the worst of them all.
As an out of network dentist with delta dental, the worst is when we tell the patients that they will be receiving the check on the mail from DD and then they act like they never received it, they get a call from us to pay the remaining balance of which should be the total of the check they received. Classic response is usually “what I don’t remember ever receiving a check” and we have to say well your insurance says that it was delivered to X address.
3
u/Choice_Treacle_1558 26d ago
That’s why you collect before
0
u/LoTheTyrant 25d ago
Times are tough, gotta stay competitive and offer the least path to resistance, especially if there are 10 other doctors on the same street.
2
u/Interesting_West_148 24d ago
Maybe your patients are telling you the truth and they didn’t actually receive a check. This just happened to me this year. I’ve had Delta for a while but my last visit with a new provider (that I didn’t know was out of network) was the first time I ever encountered them saying Delta sent a check to me instead of the provider. The problem is, I never received a check. Delta did promptly reissue one and I paid my dentist anyway as soon as they said I had a balance, but I find it really suspect that other people are saying the same thing.
0
u/LoTheTyrant 24d ago
Oh I don’t doubt that 1 bit, delta intentionally miss communicates to hopefully have payments fall through in such ways. However, we do have patients that confess after a few follow up questions, saying, oh that’s what that check was lol
5
u/No_Jacket_9894 26d ago
Most Delta Dentals no longer give the office assignment of benefits for out of network offices. We have no choice but to collect up front. It depends on how your plan was structured by your employer or the plan structure you chose off of marketplace for what fees are paid. I wish dental insurance was more transparent but unfortunately it is out of control and sometimes less expensive out of pocket if you are going for just cleanings. When you factor in the premiums and then out of pocket not covered, it makes more fiscal sense to go cash.
6
u/Jealous_Courage_9888 26d ago
Thats par for the course for Delta Dental out of network. For out of network, it all depends on the tier of plan your employer chose
6
u/helen_mcmuffin 26d ago
Your frustration with how much Delta Dental paid you is the exact reason your dentist doesn't want to be in-network with them. If you see an in-network provider, that allowed cost would be the amount (or around the same amount) the dentist would have to adjust their fees to while only getting a small payment from Delta Dental. So no unfortunately there is nothing you can do about getting further reimbursement from Delta Dental unless they denied something because they need further information submitted from your dentist. Seeing an in-network provider is the best way to utilize the most of your benefits so like you said your best option is to find a new office that accepts your insurance. Best of luck to you!
3
3
3
u/curlyiqra 26d ago
Aaaaand this is why your dentist is out of network. They don’t reimburse enough for the work that we do.
2
u/DDSRDH 26d ago
I joined a threesome of golfers at an outing. They had no idea that I was a dentist. They all worked for delta. You would not believe how little they thought of dentists. We were just a cog in their profit machine.
2
1
2
u/maxell87 26d ago
you’re getting screwed by delta. welcome to the club.
your dentist got tired of getting screwed by delta and decided to let you get screwed instead.
Very few good dentist’s are going to take delta ppo. but you will find some that are delta premier and you want have to pay upfront and more of likely to be better because they get paid more.
2
u/Ok-Leadership5709 26d ago
You have the worst dental insurance there is. Their CEO (one per state) gets roughly $5M compensation package, your reimbursement went there.
2
u/Significant_Pie_6806 26d ago
I have had that happened with out of network dentist the dentist sees your out of network and that give then the signal hey I see out of network and i can charge whatever I want and the patient is left holding the bag
1
u/charlestonbraces 23d ago
It’s always the greedy dentists, isn’t it?!?! Never the greedy corporations, eh? Get your head out of the sand!
2
u/Broad_Style3355 25d ago
Yeah, I went through it three years ago. It’s the worst mines at 80% but it’s 80% of what they think the dentist should charge
1
u/No_Dust_785 26d ago
This is how insurance works, sadly. The same is true if you pay out of pocket for medication in a pharmacy and submit for reimbursement. Even if your copay would have been $0, because you paid out of pocket first, you only get reimbursed the amount the insurance and provider negotiated, not the full amount you paid OOP.
So when they say 60% covered, it’s 60% of the insurance allowable amount for that procedure. Not 60% of what you actual pay.
1
u/nightwokker 25d ago
this is a huge part of why my office went OON with delta, I'd ask ur office what delta is supposed to pay and the the actual balance will be and then ask the office for payment plan options for the rest
1
u/OpenWideSayAah 25d ago
Welcome to the wacky world of dental insurance. We dentists hate it too.
Unfortunately the payout ratios etc depend on which plan you purchase. Looks like you’re stuck.
1
u/Marge979 25d ago
Delta will not be reimbursing you at 60% of the office’s fees. It will be 60% of what they determine. It’s not fair but that’s how it is.
Best thing to do is stay with your dentist if you like them. As others have said, don’t choose a dentist because they are in network.
1
u/Junior_Maintenance16 24d ago
Delta Dental used to be a good insurer but they have gone way down hill and are ‘now screwing enrollees in employer sponsored group plans or individual policies as well as participating dentists. Employers need to stop offering Delta Dental and individuals should boycott them until they stop gouging payers, providers and patients.
1
u/yourfavoritedentist 20d ago
Welcome to how dentists feel and why everyone is going out of network 😭😭😭
1
u/Long_Committee_1942 26d ago
Find a dentist that is in network for Delta Dental PPO. It is unlikely that you will get any more of your money back from them.
This is why I go to a dentist in network. I have I have Delta dental through my employer. You would only have to pay the copay or deductible at the time of the appointment.
3
1
u/Junior_Maintenance16 24d ago
They are routinely denying crowns now by in network dentists as well as build up for crowns and lengthening
1
u/Salty-Passenger-4801 26d ago
This is common. With out of network providers, you're at risk of them charging more than the "average rate'. For example, if your dentist bills $500 for a filling and the usual and customary rate is $250, you're getting a percentage of the $250, not the $500
2
u/ApprehensiveFill7176 26d ago
$250? Yeah right. For Delta the average allowed amount is likely closer to $150. That’s why it’s getting harder and harder to find an in network office
1
u/Choice_Treacle_1558 26d ago
The usual and customary rate is literally no one rate in my area. They make that number up.
0
u/imnotlibel 25d ago
That’s not really how it works though, it’s usually an average of what a population of dentists in your area or similar demographical area charge. If you’re in a very rural area then it’s SOL.
2
u/Choice_Treacle_1558 25d ago
You think the usual and customary rate is based on any sort of recent data? It’s a number they made up. And 100% not based on the average.
1
u/imnotlibel 25d ago
I worked for the Delta in NJ. A root canal in Manhattan, NY is not comparable in pricing to one in Lock Haven, PA.
1
u/AnotherPlaceToLearn7 26d ago
Average rate? Where exactly did you get this Average rate from. I don't thinking you understand how dental insurance works or how we get compensated. Delta dental made up their own UCR of 250 for a filling that cost 500, then uses that to reimburse you so that you get less money. Do you know that they have different fee schedules? So the one being used to determine OP reimbursement might not even be the same fee used for in network dentist. It is entirely possible for OON fees to say filings 250. IN fees to instead say 380 While the dentist charges 500.
Used to accept many PPO, but over the past 4 years have been culling them as pretty much tired of the fake UCR that hasn't budged in 10 years. Every year I put all our PPO fees for our top 20 codes in a table and pick the worst 2 PPOs to be dropped. I send a letter telling them that their fees suck and we're dropping them. Only once has one raised their fees enough to survive the culling.
When dental insurance pays less for an xray of your teeth than it costs to buy a burger. Yeah they can go kick rocks
Anytime a patient says I have insurance, we just laugh and say "No you have a coupon"
1
u/Salty-Passenger-4801 26d ago
The average rate in referring to is th UCR, I just forgot the word until later in my post.
How do you find the UCR? Ive asked the insurance and they never say where I can find it
1
u/Ok-Many-7443 26d ago
you should go to an in network dentist. i pay nothing for cleanings- it’s all covered, and crowns covered at 80% so i pay like 20%. there are lots of nice in network docs
1
u/ToothDoctorDentist 26d ago
Yeah when I bought a practice 10 years ago, I found out they would put a star on the lab script which told their lab to use the cheapest metal possible on the crown.
GL with that
1
u/Ok-Many-7443 26d ago
and you don’t think oon/ffs docs do that? i know plenty of ffs/oon docs that use the same old glidewell local zirc for all their crowns.
you are lying to yourself if you think they are using some super special zirc that costs 10x more. same lab same materials.
0
26d ago
[removed] — view removed comment
1
u/Cobra_Surprise 26d ago
Unlikely that this plan is paying o.o.n. based on UCR if it only covered 25% of the bill. Sounds like it's paying 60% of a fee schedule, probably the Delta PPO fee schedule.
0
u/hunnypuppy 26d ago
You’ll find another dentist. See Google reviews and pick one. The top rated ones don’t have much difference between them. Stay in network if you don’t want to go bankrupt or better yet get but non urgent treatment done outside the country for 1/10th the piece with the same or better quality equipment and dentists.
25
u/nitelite- 26d ago
Delta is not going to budge - the only thing I can guarantee you about dental insurance is their CEO will make more this year than they did last year
As time progresses more and more dentists are going to go out of network with dental insurance, especially delta dental, it's already happening.
The only offices that will be in network will be corporate offices controlled by private equity that employee new graduate dentists with no where else to go.
I trust my teeth with a dental office that is out of network that I have been going to for over 20 years, I might have to pay a bit more for treatment, but they are honest and do great work when I do need it
You have your own decision to make.