Delta Dental holds the title as the most extensive administrator of dental benefits in the United States. A sizable proportion, approximately 34%, of all dental claims nationally are processed by Delta Dental. However, the experience dental practices have with Delta Dental can significantly differ.
But why is this the case?
Delta Dental operates within 52 service areas, which include the 50 states, the District of Columbia, and Puerto Rico. There are 39 companies that have licensed the Delta Dental brand, with some of them operating in multiple service areas. The Delta Dental licensee for a particular state is the sole authority that can establish contracts with dentists operating within that state. Moreover, these licensees are responsible for quoting employers whose corporate headquarters are situated in that state.
For instance, Walmart's headquarters is in Arkansas. Hence, all claims for Walmart members in any state are processed by Delta of Arkansas. For example, if a practice in Michigan is treating a patient that is employed by Walmart, Delta of Arkansas issues the reimbursement, but the provider contract and fee schedules of Delta of Michigan still apply.
Adding to the complexity, the 39 Delta Dental companies utilize 17 different processing systems. Each of these systems may have unique nuances in terms of how they apply edits to claims. They also differ in their approach to revenue focus, utilization management, and attachment requirements.
Delta Dental has several networks:
Among these, the Delta Dental PPO and Delta Dental Premier are the most prominent. Roughly 50% of all dentists participate in the PPO network, and over 80% are part of the Premier network. Some states only allow dentists to participate in the Premier network, while most require participation in both PPO and Premier networks.
The strategies for discount levels and reimbursement also show variation. Some have annual increases, while others may not increase for 3-5 years at a time. Only a few Deltas have been known to negotiate fees. In the 1980s, Deltas typically had one region, and their reimbursement methodology was based on submitted claims, with annual increases following the trend.
However, the landscape began to shift around 2005. Non-Delta plans halted their yearly fee increases. In 2008, they started using multiple networks and controlling fees more aggressively. This strategy was further emphasized when MetLife began using multiple networks in 2012. Nowadays, it is commonplace for payers to use 3-6 networks simultaneously, some even utilizing as many as 8. For example, any payer could lease Careington, Connection Dental, and DenteMax and would match The Delta Dental PPO in both size and discount.
In the pool of patients with benefits administered by Delta Dental, only about 35% will have insured products. Insurance is regulated by the Department of Insurance of each state, leading to variations between states. These plans are standardized, filed each year, with minimal changes.
On the other hand, the remaining 65% of the plans are self-funded. This means the employer is funding the claim. These plans are governed by the Employee Retirement Income Security Act of 1974 (ERISA), and Federal law supersedes State laws. Each of these self-funded plans can have differing benefits, frequency limitations, etc.
For instance, a state could pass an assignment of benefit law, and all self-funded employers could opt to ignore it.
While it might be convenient to envision the 39 Delta Dental companies operating in 52 service areas as a unified, seamless entity, the reality is far from it. Each entity is distinct, and the experience for providers varies significantly from one state to another. Navigating this intricate landscape requires a nuanced understanding of each entity's operations and regulations.