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Articles
2002 Annual Report Now Available
Dental Reminders
NJ Dentists, Foundation Team to Treat
Thousands of Needy Patients
How DeltaUSA Links Participating Dentists Into
National Network
Online Claims Submission Tips: Why Claims Submitted
Using Delta Dental's Internet Solution May Pend
License Number Submission Tip
Insurance Fraud: Can You Afford to Look the
Other Way?
Payment Policy Clarification Regarding Consultations
and Evaluations
Electronic Claims Increasing Steadily
Quick Tip on Patient Identification
Results of Delta Dental Classic Available Next Issue
New In-Net Program Available
Delta Dental Days Winners Announced; New Programs Scheduled
2002 Annual Report Now Available
In 2002, Delta Dental added nearly 100,000 new subscribers,
while remaining firmly committed to providing outstanding
programs and customer service. These were just some
of the highlights of our 2002 Annual Report, which
is now available.
Other highlights include:
- Launching our Claims Inquiry feature, which enables
dentists to review claims history in a secure area
of our Web site, and Online Claims Submission,
an easy and efficient way to submit claims.
- Achieving an impressive "AA-" Standard &
Poor's rating of our financial strength for the
third consecutive year. S&P predicted a stable
outlook for Delta Dental, citing our extremely
strong capitalization, excellent earnings, and
good business position.
- Details of our Foundation's efforts, which include
donations for a first-of-a-kind dental clinic for
people with disabilities, two dental care clinics
for New Brunswick public school students, and critical
oral health research for minority populations.
To request a copy of the 2002 Annual Report, visit
our Web site at www.deltadentalnj.com and click on "Our
Company" on the navigation bar on the left side
of the home page.
Dental Reminders
Please fully complete claim forms, and include required
diagnostics and other attachments when submitting
claims. This will help avoid delays that result when
we must request the missing information in order
to make a benefit determination.
Please respond to our request for missing information
only once. As part of the New Jersey Prompt Pay law,
Delta Dental is required to make a "good faith
effort"
to acquire missing information by phone, fax, or
e-mail prior to mailing a letter requesting that
information. We currently fax to your office notices
of missing information, then follow-up with an Explanation
of Benefits (EOB). If you sent the requested information
in response to the fax, it doesn't need to be sent
a second time when the EOB is received.
NJ Dentists, Foundation Team
to Treat Thousands of Needy Patients
The Donated Dental Service (D.D.S.) program of The
New Jersey Foundation of Dentistry for Persons with
Disabilities (NJFDPD) has reached a major milestone.
The total value of donated treatment since its inception
in 1989 has surpassed $8 million.
To date, 775 New Jersey dentists have volunteered
their time and effort to treat patients that normally
would have fallen through the cracks of our present-day
healthcare delivery system. Major funding for the
program is provided by Delta Dental Plan of New Jersey
Foundation, Inc.
The D.D.S. program treats patients who are unable
to afford treatment, or have compromised medical
status or physical disabilities that affect access
to dental care. More than 5,000 patients have received
treatment as a result of the program, and more than
250 patients are currently undergoing care.
Dr. John Feeney, president of the NJFDPD, notes
that there are many more needy patients to treat
and more volunteer dentists required to care for
them. If you would like to volunteer, contact Donated
Dental Service at 732-821-2977. For more information
about NJFDPD, visit the National Foundation of Dentistry
for the Handicapped Web site at www.nfdh.org.
How DeltaUSA Links Participating
Dentists Into National Network
Delta Dental Plan of New Jersey is part of a nationwide
system of dental health service plans. As a participating
dentist with Delta Dental Plan of New Jersey, you
are also part of the nationwide DeltaUSA network.
This means that you may see patients who have coverage
from other Delta Dental Plans, and be reimbursed
as you normally would be with Delta Dental Plan of
New Jersey, Inc.
The DeltaUSA program was developed to accommodate
employers with locations in many parts of the country.
It enables them to provide quality, uniform dental
benefits programs to groups with a multi-state labor
force. This is why some of your
"Delta Dental" patients who live in New
Jersey or Connecticut may have coverage with another
Delta Dental. So, although you submit the claim for
those patients to a different Delta Dental Plan,
you will be reimbursed at Delta Dental Plan of New
Jersey rates.
If you have questions, please contact your Dental
Network Coordinator at 888-396-6641. Dental offices
may call this number to obtain a list of all Delta
Dental Plans (with 800 numbers and their addresses).
Online Claims Submission Tips:
Why Claims Submitted Using Delta Dental's Internet
Solution May Pend
Online claims submitted to Delta Dental pend for
various reasons, some because of situations we need
to research and some because of situations your office
can watch out for.
Situations Dental Offices Should Watch Out For
- Verify you typed the correct tooth code and tooth
surface. If you type a tooth number or code that
does not match the procedure you are performing,
our system checks will pend that claim.
- Make sure you fill in a fee for your submitted
amount. Failure to do so will pend the claim and
we will have to call your office to find out what
fee you charged the patient for that procedure.
- Make sure you correctly type the patient's and
subscriber's information (name, address, relationship
code). If our system doesn't find an exact match
with the information you provided, additional research
will have to be done on our end to figure out who
the patient is and if the patient is eligible for
benefits.
- Make sure you write comments only when necessary.
Comments cause claims to pend in order for us to
reach them and process the claim accordingly.
Situations You Can't Control
- Diagnostics needed. The claim will pend until
the diagnostics are received and reviewed.
- Procedure is already in history. We will have
to research to see if the patient is eligible for
the service.
- Processing notes for special circumstances.
Please do not send in a duplicate claim if you have
already submitted one online (or on paper). The quickest
way to find out the status of a claim is to use Benefits
Connection at www.deltadentalnj.com; click
"Dentists" and log on to Benefits Connection.
License Number Submission Tip
When you submit online claims, Step 1 asks you to
choose a dental license number associated with the
TIN with which you registered. If there is more than
one license associated with your TIN, you will see
one address listed, with a drop-down selection of
other offices.
Please carefully select the license and location
for the dentist who treated the patient so we can
be sure to mail your check to the right location.
Once you select the license number to be paid, your
claim goes through without further checking of the
license number, since all numbers offered to you
are valid license numbers.
If you have any questions about license numbers
or TINs, please contact our Professional Relations
Department at 973-944-4588.
Insurance Fraud: Can You Afford
to Look the Other Way?
Organized crime has traditionally been the high-profile
target of the Department of Justice. However, the
most sought-after lawbreakers in recent years have
been those who commit healthcare fraud. Healthcare
fraud is an intentional deception or misrepresentation
that a person or entity makes knowing that the misrepresentation
could result in an incorrect payment or benefit.
Published reports estimate that medical professionals
account for about 72% of suspected healthcare fraud.
Billing for services not rendered and upcoding is
estimated to account for about 56% of this suspected
fraud. Penalties can be very severe. Guilty parties
can be providers, subscribers, insurance companies,
brokers and groups, as well as anyone knowingly benefiting
from someone else's insurance fraud. Carriers who
do business in New Jersey are required (under heavy
penalty) to report all reasonable suspicions of health
insurance fraud to the state's Office of the Insurance
Fraud Prosecutor (OIFP), which investigates and pursues
violators. Additionally, insurance companies must
maintain special investigative unites, and provide
anti-fraud training to all claims processing and
underwriting staff.
We All Pay the Price for Fraud
Many people view insurance fraud as a low-risk activity
that can generate large rewards. Consumers often
feel that insurance fraud is acceptable, a crime
without an apparent victim. In truth, insurance
fraud victimizes all of us. This attitude makes
it easier for wrongdoers to operate.
Studies show that two out of three Americans will
tolerate insurance fraud to varying degrees. One
reason may have something to do with the way health
insurance policies are structured. Most health insurance
policies are structured so that the subscriber and
the insurance company share treatment costs. This
helps keep premiums lower, and helps to insure that
the services or treatments billed for were actually
rendered. Very few people will pay for something
they did not receive.
Unfortunately, many consumers do not understand
their coverage or their benefits. When people find
out they must pay expenses they assumed their insurance
would cover, they often perceive the insurance company
as being unfair. Because of this view, two-fifths
of the American public feels that there should be
little or no punishment for insurance fraud.
Most people are probably unaware of the high price
they already pay for this criminal activity. Insurance
companies must pass on the large cost of insurance
fraud to policyholders. This drives up everyone's
insurance costs and in turn causes the cost of consumer
good to increase. Prices of clothes, appliances,
automobiles and food all rise when businesses must
pass on the higher costs of their employee health
insurance coverage. Honest businesses lose money
and may close because fraud increases their operating
costs. Individual subscriber coverage may be drained
by unnecessary or fraudulent services, and taxes
are higher because billions of tax dollars pay for
fraudulent insurance claims every year.
Health insurance fraud accounts for an estimated
10% of the annual expenditure on health care in the
United States. Studies show that a 1% rise in insurance
premiums results in approximately 400,000 more people
nationwide who cannot afford health insurance at
all. Other types of insurance fraud include auto
insurance fraud (which costs the insurance industry
an estimated $14 billion each year), workers' compensation
fraud ($2.1 billion annually), Medicaid fraud, collecting
illegal unemployment benefits, collecting illegal
Social Security disability benefits, collecting on
false homeowners' property damage, buying or selling
fake automobile insurance identification, identity
theft, and many more.
New Jersey Educates Public About Fraud
Many states, including New Jersey, have begun educating
consumers about the cost of insurance fraud. This
includes an advertising campaign geared to create
public awareness. Tips are given on how to detect
fraud, as well as how to report fraud. The messages
put out to the public stress simple themes:
- Insurance fraud is a crime.
- Everyone pays a high price.
- Getting caught has heavy consequences.
- There is a strong likelihood of getting caught.
How to Report Fraud
If you think you have knowledge of a fraud, contact
the insurance carrier listed on the Explanation
of Benefits statement. The insurance company may
be reached by telephone, letter, or e-mail. Most
insurance carriers also have Web sites that contain
specific instructions for reporting fraud.
Delta Dental Plan of New Jersey can be reached at reportfraud@deltadentalnj.com.
Delta Dental also has a Fraud Hotline at 888-696-3262.
In the State of New Jersey you can also contact
the Office of Insurance Fraud Prosecutor at www.njinsurancefraud.org,
or at 877-55-FRAUD (37283).
Fraud An $80 Billion Per Year Crime
Insurance fraud is the second costliest white-collar
crime, exceeded only by tax evasion. People of
all races, incomes, and ages are victimized. The
Coalition Against Insurance Fraud estimates that
insurance fraud costs Americans $80 billion a year.
Each family pays nearly $950 in added expenses
each year because of insurance fraud; there is
also an increase of $200 to $300 in insurance premiums
for the average household.
Think of insurance fraud as an $80 billion a year
crime wave. Here's what that kind of money could
do if it weren't being fraudulently diverted:
- Fund the entire United States space program for
five years.
- Buy more than twice the gold stored at Fort Knox.
- Pay the college tuition for 12 million
undergraduate students each year.
- Fund AIDS treatment, prevention, and research
for the next eight years.
- Make insurance fraud at "Fortune 10"
corporation, if fraud was a company.
Payment Policy Clarification
Regarding Consultations and Evaluations
The following are Delta Dental's payment policies
for consultation (D9310). The fee for a consultation
is DISALLOWED when billed in conjunction with an
examination/evaluation by the same dentist/dental
office.
The fee for a consultation in connection with non-covered
services is DENIED and the approved amount is collectable
from the patient.
Consultation (D9310) may be benefited when the service
is provided by a dentist or dental specialist whose
opinion or advice regarding an evaluation and/or
management of a specific problem may be requested
by another dentist, physician or appropriate service.
The dentist performing the consultation may initiate
diagnostic or therapeutic services.
When covered, the consultation is subject to the
same frequency limitations, co-payment levels, and
processing policies as a comprehensive evaluation
(D0150).
Electronic Claims Increasing
Steadily
More dentists than ever submitted electronic claims
last year. According to Delta Dental's 2002 Claims
Operations and Customer Service Network Development
Report, nearly 1.2 million claims were submitted
electronically last year--41% of all claims.
Electronic claims are easy to submit. Plus, dentists
receive payment faster than with paper claims. The
average cycle time for e-claims in 2002 was 10.21
calendar days, or just 6.95 business days.
To find out how your practice can begin submitting
e-claims, contact your Dental Network Coordinator
at 888-396-6641.
Delta Dental recently joined with Dental Connect
to offer dentists the opportunity to submit free
e-claims through their practice management software
systems. For more information, contact Dental Connect
at 800-624-2904, and select option 3.
Quick Tip on Patient Identification
Q. How can a dental office help protect itself against
a patient fraudulently using another person's dental
benefits?
A. Dental insurance is a valuable employee benefit.
Recently, we have seen several cases where people
pose as Delta Dental subscribers to gain coverage
to which they are not entitled. There are costly
implications to this type of misuse, from increases
in the dental insurance premium to loss of revenue
for the dental office. To help prevent this type
of fraud, Delta Dental Plan of New Jersey recommends
that you ask for a form of photo identification such
as a driver's license or passport. You should make
a copy of it for the patient's record or note in
the chart that a photo ID was presented and checked.
Delta Dental Plan of New Jersey reserves the right
to recoup any money paid for services rendered to
a non-covered person.
Results of Delta Dental Classic
Available Next Issue
As this issue went to press, golfers were practicing
their swings in preparation for the Thirteenth Annual
Delta Dental Classic, which was scheduled for June
4. The Golf Classic raises funds for Special Olympics
New Jersey (SONJ), a non-profit organization that
provides athletic training and competition for children
and adults with mental retardation. Results of the
event will be published in the next issue of Dental
News.
New In-Net Program Available
Delta Dental's In-Net program offers participating
dentists discounts on a number of products and services
that can benefit your practice. The newest In-Net
partner is CPRofessionals, Inc., which offers training
classes in CPR, first aid, blood-borne pathogens,
and AED, as well as a Hepatitis B vaccination program.
All classes are taught at a time and location convenient
for you. For information, please call 888-4-CPR PROS
(888-4-277-7767).
To learn more about In-Net discounts for participating
dentists, visit our Web site at www.deltadentalnj.com
and click on "In-Net Program" in the
"Dentists" section, or contact your Dental
Network Coordinator at 888-396-6641.
Other In-Net Discounts
Delta Dental also offers discounts for our participating
dentists for:
- MVP Practice Management Discount Program
- Free Internet Home Page
- Safari Telecom Sprint PCS Wireless Discount Program
- Safari Telecom Telephone Systems Discount Program
- Steri Check Sterilizer Monitoring Service
- HealthFirst Medical Emergency Products
- ProfitFinder Price Comparison Shopping Service
When you contact these vendors, please identify
yourself as a Delta Dental Plan of New Jersey participating
dentist. They will lead you through the enrollment
process. Please note that these vendors will deal
directly with you. Delta Dental will do its best
to maintain these vendors to provide even more value
to you. However, Delta Dental does not guarantee
the performance or continued participation of these
vendors. This program has been designed to provide
savings opportunities to our participating dentists.
Delta Dental Plan of New Jersey does not receive
any compensation from any vendor under this program.
Delta Dental Days Winners Announced
Congratulations to Anne McAuliffe, who works for
Dr. Gary S. Millinger in Hartford, Connecticut, and
Pat Walsh, who works for Dental Associates of Connecticut
in Danbury, Connecticut. Each won $100 in a raffle
at a recent Delta Dental Day program in Connecticut.
Delta Dental Days are a series of free educational
seminars offered by Delta Dental to participating
dentists and their office staff. The next Delta Dental
Day programs are:
October 1, 2003
Renaissance Hotels
801 Rutherford Avenue
Rutherford, New Jersey
October 8, 2003
Renault Winery & Tuscany House
72 North Bremen Avenue
Egg Harbor City, New Jersey
October 15, 2003
Westin Morristown
Two Whippany Road
Morristown, New Jersey
The half-day seminar runs from 9 a.m. to 1 p.m.
and covers:
- The different types of programs Delta Dental
offers
- Electronic claims - how to get started and helpful
tips
- Delta Dental's HIPAA compliance efforts
- Delta Dental's use of processing policies in
claims processing
- Preventing fraud and abuse
- How to use our new Benefits Connection feature
to verify patient eligibility and benefits on the
Internet to save your practice time, improve patient
relations, and improve your cash flow when using
it to submit claims
Registration information will be sent in August
2003.
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