The Delta Difference

April 25, 2025

The Delta Dental Difference Is Cost Management At Its Finest

Delta Dental has developed an aggressive cost management strategy called The Delta Dental Difference. The Delta dental Difference includes no balance billing, fee audits and professional review.

The Delta Dental Difference is Delta Dental's exclusive five-point cost management system that consists of the following elements:

Statewide and Nationwide Dentist Networks
Maximum Plan Allowance
No Balance Billing or Cost Shifting
In Office Audits
Claim and Utilization Review

The Delta Dental Difference means lower costs for employers and lower enrollee out-of-pocket costs, too.

In 2005, The Delta Dental Difference and other cost savings mechanisms resulted in book of business cost savings of more than $128 million.

1. Statewide and Nationwide Dentist Networks

Seventy-five percent of all practicing dentists in the country and seventy percent in Illinois participate in our managed fee-for-service Delta Dental Premier network, providing our groups and enrollees with valuable cost and quality assurances. Delta Dental offers an exclusive network combination - Delta Dental Premier works in conjunction with our extensive Delta Dental PPO network (more than 88,000 dentist location nationwide and 3,000 in Illinois), to provide unparalleled access and cost savings. Enrollees have the option to go to PPO, Delta Dental Premier or out-of-network dentists at the time of treatment (i.e., no need to choose dentist or one network or the other at enrollment).

On average, 75 percent of all Delta Dental enrollees nationwide go to either Delta Dental Premier or Delta Dental PPO network dentists. This is a significant source of savings for both clients and employees that other dental carriers do not provide.

2. Maximum Plan Allowance

Delta Dental of Illinois establishes maximum plan allowances (MPAs) for all procedures for Delta Dental Premier dentists. Delta Dental's maximum plan allowance methodology and cost management protocols typically generate in-network claim savings of five to ten percent as compared to traditional fee-for-service plans.

Delta Dental Premier network dentists accept our MPAs as payment-in-full and cannot balance bill or "cost shift" Delta Dental patients for any difference between their submitted charge and the amount we allow.

Reimbursement to Delta Dental Premier network dentists is based on the lesser of network dentists' filed fees or Delta's proprietary MPAs. Delta Dental Premier network MPAs are pegged at varying percentiles according to each Delta Dental member company's contractual agreements.

Clients and their enrollees will realize significant savings on Delta Dental Premier network claims compared to other carriers' out-of-network traditional, non-managed indemnity plans because of our a) lower overall reimbursement levels, and b) sophisticated cost management mechanisms. These savings are in addition to savings that clients will realize through the Delta Dental PPO network and are quantified in our cost management reports.

3. No Balance Billing or Cost Shifting

Many enrollees realize significant out-of-pocket savings from our industry-exclusive "no balance billing" provision prohibiting network dentists from billing Delta patients for any difference between their submitted charge and the amount Delta allows (i.e., the maximum plan allowance). Enrollees only have to pay deductibles and copayments required by their employer's plan.

In addition, network dentists cannot bill Delta Dental patients for charges Delta Dental does not allow, such as "unbundled" services that should be billed as one procedure - so there's no "cost shifting" to enrollees. Enrollees know the maximum amount they'll pay and are protected from unexpected charges.

Delta Dental of Illinois has a sophisticated adjudication system that automatically compares procedures reported on claims in progress with those previously processed in claim history. When deviations are identified, claims are suspended for review by a dental auditor with expertise in dental treatment.

Many dentists unbundle (i.e., split procedures into component parts) in order to generate additional fee income. This is one of the many areas where Delta's cost management expertise pays major dividends for its clients.

All procedures affected by unbundling have been entered into a special system edit table that automatically disallows the component procedures while allowing the appropriate bundled procedure.

As the nation's premier dental benefits carrier, Delta Dental has used dental consultants representing each region of the country to develop standard processing policies. These uniform rules apply to all dentists in Delta Dental's networks so when unbundling occurs the enrollee is protected from inappropriate charges.

An important cost-savings is that Delta Dental Premier and Delta Dental PPO network dentists cannot shift these costs, i.e., balance bill, Delta patients for disallowed amounts.

4. In-Office Audits

We conduct periodic in-office audits of Delta patient records. This ensures the charges to Delta patients are the dentist's usual charges and the services billed were actually performed.

5. Claim and Utilization Review

Delta Dental Illinois (DDIL) features a unique quality assurance and utilization review program, backed by 40 years of experience in dental benefits and cost containment.

Claim Review

DDIL's state-of-the-art claims processing system provides reports that analyze network dentists' utilization patterns to identify dentists that demonstrate aberrant treatment patterns as compared to "norms."

DDIL's dental director is an actively practicing dentist experienced in reviewing claims for appropriateness of care. This is accomplished by: a) interpreting x-rays and narratives; b) identifying aberrant treatment patterns (over/under- utilization); c) identifying components to more comprehensive procedures; and, d) detecting fraudulent or abusive treatment patterns. DDIL also has consulting contracts with two general and five specialty dentists, all of whom are in private practice and have a minimum of five years experience reviewing dental claims, to assist our dental director on an as-needed basis. DDIL does not charge separately for its professional consultant and claim review services.

Approximately four to five percent of our claims are reviewed by our dental director. Claims routed to our dental director are typically high cost, low volume procedures that require a dentist's opinion as to the level of benefits available under the group contract. The dental benefits booklet identifies these procedures and the documentation required to make a benefit determination. Procedures are selected for review based on evaluation of a) quality assurance; b) potential fraud or abuse; and c) contractual limitations of benefits.

Utilization Review
DDIL conducts utilization review by targeting specific procedures performed by dentists, which when compared to carefully developed norms, may indicate irregularities in practice patterns compared to the entire dental population from whom we receive claim data. DDIL uses PULSE (Professional Utilization Statistical Evaluation), a statistical methodology to identify aberrant utilization patterns of dentists to facilitate more targeted claim review and network management efforts.

Professional relations staff will run post-payment utilization reports from the claims system for all Delta Dental PPO and Delta Dental Premier® dentists no less than annually. They will also run utilization on dentists for whom we have received quality of care complaints.The utilization report scores and ranks the practice patterns of a particular dentist to that of the entire dentist population for claims processed for the previous year. Five key indicators are used to compare dentist utilization patterns:

Charges per patient
Number of dental procedures per patient
Number of x-rays per patient
Number of scaling and root planings per patient
Number of crowns and onlays per patient

Dentists are evaluated for each measure and on a composite basis across all five measures. Dentists are ranked in descending order by the number of standard deviations from the mean for each measure and across all measures on an aggregate basis. Profiles can be created across states, within a state, by geographic area within a state, by measure, by network type (e.g., Delta Dental Premier/Delta Dental PPO).

More detailed utilization information is available as necessary. Forty additional procedural tests can be generated to further identify claim reporting issues. Comparisons that vary from the norm, considering the established standard deviation, are indicated with + or -. The reports that indicate deviations from the norm are sent to the dental director for further review. The dental director will analyze the reports to detect procedure splitting, treatment irregularities (over-treatment, under-treatment, re-treatment), overcoding, and many other abnormalities in the provider profile. If recommended by the dental director, a dentist may be set up for prepayment review for any given procedure. Based on variances noted, professional relations representatives and/or the dental director will contact the dentist to discuss the results of the study.

DDIL is able to focus network management action plans, claim reporting guidelines, and professional review of claims on targeted dental offices versus subjecting all claims/dentists to the review process, which is a much more efficient way to identify aberrant utilization patterns and report findings to dentists with comparative measures.

Professional Review
We have a network of 200 regional consultants (all of whom are licensed practicing dentists) who can conduct clinical second opinions on patients deemed to have been inappropriately treated.

Our credentialing guidelines follow NCQA recommendations. DDIL functions in a consultative role concerning network dentists' practice patterns, quality of care concerns, and compliance with program guidelines. We conduct site evaluations regularly and provide feedback based on professional claim review and statistical analysis of treatment patterns. We conduct post-treatment chart reviews on a complaint basis.

When a dentist fails to perform within standards of care and/or adhere to contractual obligations or Delta Dental's policies, our director of quality assurance visits him/her to discuss our concerns and establish a timeframe for correction and re-evaluation. If the dentist does not meet the agreed upon performance measures, he/she is terminated from the network. Once a dentist is terminated involuntarily, he/she must reapply and be approved for reinstatement by the quality improvement committee.