Understand its limits

Delta Dental is a dental insurance company that was started by a panel of dentists. Originally they wanted to provide dental insurance that would preserve the quality of dental care in the best interests of the patient. However, they were hit with the realities of the marketplace, and in order to continue to thrive as a dental insurance company, they felt great pressure to control costs.

Delta Dental was one of the first dental insurance plans to be based on a membership contract with dentists. This gave them certain power to dictate treatment. If a dentist wanted to be a member of the plan, he or she needed to agree to whatever restrictions Delta Dental imposed. At first these restrictions were very reasonable, but with the increased cost containment pressure from Delta Dental, they became less reasonable.

In the early days of Delta Dental, they created a formula for the fee levels that they would expect, based on statistical data gathered from participating dental offices. They compiled a fee list of what were called "reasonable and customary" fees, and as long as a dentist's fees fell within that range, they would accept that fee. With increased financial pressure, they felt they had to set their own fee structure and not base it on a survey. They continued to use the term "reasonable and customary" fee, but removed any linkage to what fees were actually being charged by participating dentists.

What made the restrictions particularly objectionable was the attempt by Delta Dental that they were taking the moral high ground, taking an accusatory tone toward participating dental offices that resisted their restrictions, and not owning up to their own financial motivations.

Other related information:

• What is meant by the term preferred provider?
• You can also look into how a privately purchased dental plan could help you get discount care.
• What is meant by the term usual and customary fees?