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Articles
2002 Annual Report Now Available
Cost Containment Report Released
Six Reasons to Start Submitting Eligibility
Changes Online
Compliance with New DOL Laws
Insurance Fraud: Can You Afford to Look the
Other Way?
How to Report Fraud
Delta Dental Joins Fight Against Breast Cancer
Changes Announced to Automated Voice Response System
Privacy Practices Distributed
Only a Few More Days Until the Delta Dental Classic
Fraud an $80 Billion Per Year Crime
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:
- Receiving our highest marks to date in our annual
survey of benefits managers. More than nine out
of ten benefits managers said they are "extremely
satisfied" or "very satisfied" with Delta Dental.
In addition, 98% of benefits managers said they
would recommend Delta Dental to other administrators.
- 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.
Cost Containment Report Released
Delta Dental saved our groups more than $200 million
last year, thanks to our cost containment measures.
These efforts enable groups to manage their expenses
wisely while providing Delta Dental's excellent dental
benefits programs to their employees.
To view our complete "Cost Containment Report for
2002," visit our Web site at www.deltadentalnj.com
and click on "Employers" and then "Cost Containment."
Six Reasons to Start Submitting
Eligibility Changes Online
1. It's convenient. There's no paper to handle,
and no need to leave your desk in search of a fax
machine. Everything can be managed right from your
computer.
2. It's user-friendly. The system will guide you
step-by-step through the submission process. It even
lets you know if you've forgotten anything!
3. It simplifies record keeping. You can easily view
submissions and profiles, and print out reports.
4. It's secure. Information is password-protected
and safeguarded against unauthorized access.
5. It's fast. Benefits changes take effect in 24
hours, or less.
6. It's easy to register. It takes just a few minutes
to get your password from Premium Billing. Call (973)
285-4144 anytime Monday through Friday from 8 a.m.
to 4:30 p.m. Then, go to www.deltadentalnj.com, click "Employers," and
sign into the Administrator's Logon area. You're
ready to go!
Compliance with New DOL Laws
The United States Department of Labor recently adopted
regulations governing claim adjudication and appeals
for group health plans governed by ERISA (Claim Procedure
Regulations-Title 1-29 CFR 2560.503-1). The new claims
and appeals procedures apply to all ERISA plans,
whether insured ("risk") or self-funded ("ASO" or
"ASC").
This process applies to all ERISA plans for which
Delta Dental provides coverage or administration.
Delta Dental is also applying a similar set of processes
to non-ERISA plans for which we provide coverage
on a risk basis.
Some key points include:
- Predetermination of benefits is not required.
However, patients and their dentists may request
a predetermination to obtain advance information
about the plan's possible coverage of services
before they are rendered.
- Patients and dentists will usually be notified
in writing within 30 days of Delta Dental's claim
determination. If special circumstances require
extra time (not to exceed 15 days), Delta Dental
will inform them in writing.
- Explanation of Benefits (EOB) forms (sometimes
referred to as Adverse Benefit Determinations)
are the means used to inform patients and dentists
about why their claim was denied. EOBs also contain
information about Delta Dental's informal and formal
appeals processes, as well as time limits applicable
to the processes. (To view a sample EOB, go to
www.deltadentalnj.com, click "Subscribers" and
then click "View an easy-to-read description of
our Explanation of Benefits statement, PDF Format.")
A summary of Delta Dental's Benefit Determination
and Appeal Process is available at www.deltadentalnj.com;
click "Employers," then "Compliance with New Laws." This
is also available under the Home Page "What's New" section.
Our Web site also includes a description of how
subscribers or billing dentists can request reviews
of the Adverse Benefit Determination; the timeline
for such reviews; and the steps then taken by Delta
Dental during the reviews. The Web site also includes
special provisions applicable only to DeltaCare programs.
You may also obtain answers to frequently asked
questions from the U.S. Department of Labor Web site
at www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html.
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 up-coding account
for about 56% of this suspected fraud.
In 1998, the State of New Jersey established healthcare
fraud as a separate crime carrying enhanced penalties.
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 to the
state's Office of the Insurance Fraud Prosecutor
(OIFP), which investigates and pursues violators.
Additionally, insurance companies must maintain special
investigative units, 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 wrong doers 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
goods 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:
1. Insurance fraud is a crime.
2. Everyone pays a high price.
3. Getting caught has heavy consequences.
4. 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). The OIFP keeps all
tips anonymous and strictly confidential.
Delta Dental Joins Fight Against
Breast Cancer
Delta Dental Plan of New Jersey, Inc. (DDPNJ) is
known for fighting against oral disease, but now
it's joining the fight against another kind of disease:
breast cancer.
During the 2003 Delta Dental Plans Association (DDPA)
annual meeting, Gay VanBrunt, whose husband is the
president of DDPNJ, will join in a fundraising walk
against breast cancer. She also chairs the event,
which takes place on Saturday, June 21. Proceeds
from the walk will be donated to the National Breast
Cancer Coalition Fund, a grassroots advocacy group
interested in raising funds for research and improving
access to care, including breast cancer clinical
trials.
"DDPA's annual meetings are filled with goodwill
and camaraderie, and Gay is helping to turn that
spirit into a public good by participating in this
walk and collecting donations for this cause," said
Diane Belle, vice president, Corporate Communications,
DDPNJ.
Many families and friends of the Delta Dental system
have suffered with breast cancer, and the event's
organizers said they had been looking for something
the organization could do to help fight the disease
that has touched so many.
This is the first time Delta Dental has participated
in this particular charitable event.
"We always promote the idea that oral care and general
bodily wellness are linked, and this is a great way
to personify the message," Belle said.
If you would like to support this cause, please
complete the pledge form below.
Delta Dental/National Breast Cancer
Coalition Fund Pledge Form
All proceeds from the walk at donated to NBCCF
and are tax-deductible as permitted by federal
law. Please print all information for acknowledgement
and tax purposes. Thank you.
Sponsor's Name:
Sponsor's Address:
City/State/Zip:
Sponsor's Phone Number (required for credit card
donations):
Payment Type: Check _____
Credit Card _____ Cash _____
Please make checks payable to: National Breast Cancer
Coalition Fund (NBCCF)
VISA _____ MC _____
AX _____
Card Number:
Signature:
Expiration Date:
Please return sponsorships to:
Delta Dental Plan of New Jersey, Inc.
Attention: Breast Cancer Walk
P.O. Box 222
Parsippany, New Jersey 07054-0222
Changes Announced to Automated
Voice Response System
Delta Dental recently made changes to our automated
voice response system in order to comply with Health
Insurance Portability and Accountability Act (HIPAA)
privacy provisions. Subscribers must now enter their
PIN (personal identification number) in order to
access automated information about their eligibility,
benefits, claims information, remaining maximums
and deductible information. This step ensures an
additional measure of security.
Subscribers will obtain their PIN the first time
they call our automated voice response system, at
(800) 452-9310. Here's what will occur:
1. They will be prompted to enter their Social Security
number and date of birth (mm/dd/yy) on their telephone
keypad.
2. They will be prompted to enter their four-digit
PIN.
3. If they do not have a PIN, they should wait. Their
call will be transferred to a customer service agent,
who will assist them in establishing their four-digit
PIN. They will also select a security question and
answer, which will be used to verify their identity
if they forget their PIN.
Once the PIN is established, each time they call
the automated voice response system they will be
asked to enter their:
- Social Security number.
- PIN.
Except for these changes, the system will continue
operating as usual. The voice response system provides
information about subscriber benefits, eligibility,
claim status, remaining maximums and deductibles,
provider listings and how to order forms.
Privacy Practices Distributed
In April, Delta Dental distributed copies of our
Notice of Privacy Practices to all subscribers in
our fully insured groups, as mandated by law. This
policy was developed as part of our compliance with
the Health Insurance Portability and Accountability
Act (HIPAA), the federal law designed to safeguard
the protected health information of patients.
The law requires Delta Dental to take reasonable
steps to ensure the privacy of patients' personally
identifiable health information. Our Notice of Privacy
Practices provides detailed information about the
ways in which Delta Dental may use and disclose protected
health information (PHI) consistent with the law.
It also describes patients' rights and certain obligations
we have regarding the use and disclosure of PHI.
This policy became effective April 14, 2003 and is
applicable to personal health information about patients
obtained by Delta Dental on or after April 14, 2003.
Delta Dental's Notice of Privacy Practices is also
posted on our Web site at www.deltadentalnj.com.
Only a Few More Days Until
the Delta Dental Classic
There are still a few spots open for the Thirteenth
Annual Delta Dental Classic, which takes place 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. The event will
be held at Fiddler's Elbow Country Club in Bedminster,
NJ.
Last year's Classic raised $55,000 for SONJ, bringing
the total funds raised through this annual event
to more than $350,000.
For information about SONJ, go to www.sonj.org.
For registration information, call (973) 285-4059
or e-mail jappaluccio@deltadentalnj.com.
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 a "Fortune 10" corporation,
if fraud was a company.
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