Word of Mouth

Benefits administrator blog from Delta Dental

Dental fraud — what it is and how you can help fight it

Fraud accounts for an estimated 3% of the United States’ total spending on health care, according to the National Health Care Anti-Fraud Association. That may sound like a small percentage, but with dental spending in the United States projected to reach almost $200 billion by 2030, that means over $6 billion in dental fraud that year.

Dental fraud is “any crime where an individual receives insurance money for filing a false claim, inflating a claim or billing for services not rendered,” according to the American Dental Association. Fraud can take many forms, but it requires intent, deception and unlawful gain.

Fraud harms your business and your employees. It drives up the cost of coverage for you and your employees in the form of higher premiums. Every year, the average family in the United States spends an extra $400 to $700 on increased premiums because of fraud.

Common signs of fraud to watch out for

Because fraud requires intent and deception, there are signs to watch out for. Encourage employees to check their Explanation of Benefits statements and look out for dental offices that:

  • Submit claims for covered services when non-covered services are provided
  • Recommend unnecessary or expensive services when simple services will suffice (for example, recommending a crown when only a filling is necessary)
  • Report inaccurate treatments to the insurance company (for example, prophylaxis vs. periodontal maintenance)
  • Misrepresent dates of service to the insurance company
  • Fail to disclose insurance coverage to their patients
  • Refer patients to specialists when treatment is not needed

It’s entirely possible for dentists and staff to find themselves on the wrong side of the law after an attempt to help patients who might be seeking help with their coverage. Waiving coinsurance costs is one example of this. In other cases, it might be a simple oversight. Common mistakes considered fraud include:

  • Listing the incorrect treating dentist on a claim
  • Coding the wrong treatment (for example, prophylaxis vs. periodontal maintenance)
  • Altering dates of service

Fraud can also be perpetrated by dentists’ patients. Let employees know that the following actions are considered fraud.

  • Using another person’s ID or multiple IDs to obtain benefits
  • Requesting that dentists misreport dates to circumvent calendar year maximums or limitations
  • Misrepresenting available coverage to dental staff or asking them to misrepresent care to the insurance company (this includes concealing dual coverage)
  • Adding individuals to a policy who are not eligible dependents or family members

Finally, employers can find themselves on the wrong side of fraud law as well. Be sure to avoid:

  • Allowing ineligible people to enroll in coverage
  • Making inaccurate statements that can reduce workers’ compensation premiums. Such statements include misclassifying employees, underreporting employees, underreporting payroll, reporting full employees as independent contractors and misrepresenting the name under which your company does business.

What you can do to help protect yourself and employees

Fraud can happen at any point in the process of providing care, accepting payment and submitting claims. Dental offices with clear, consistently applied policies can help everyone play their part in fighting fraud. Here are some general tips that you can encourage employees to keep in mind as they choose their dentists.

  • Discuss coverage, fees and payment prior to the dentist providing services, especially for optional and non-covered services. This way employees will fully understand what their financial obligations are prior to accepting service.
  • For treatments over $300, request a pre-treatment estimate from dentists. This is a free service available to Delta Dental PPO™ and Delta Dental Premier® members. DeltaCare® USA members should review their benefit booklet for a list of covered services and applicable copayments.
  • Ask dentists if they have written anti-fraud policies and if their office staff has read and signed these policies.

To help your company avoid fraud, you can also:

  • Refer employees to the “Fight Fraud” flyer (PDF) as an educational aid
  • Implement a clearly defined anti-fraud policy and have employees sign it
  • Set up internal controls and segregate duties (for example, ensuring different sets of employees have access to plan assets and records, rather than putting one person in charge of everything)

What Delta Dental does to help prevent fraud

You don’t have to combat fraud on your own. We’re proud to be your partners in working to eliminate fraud at all levels and steps of the dental care process. What we do includes:

  • Educating our clients, members, dentists and employees about fraud detection and prevention
  • Conducting clinical patient examinations to ensure that provided services meet professional standards and were correctly submitted
  • Reviewing financial and treatment records to ensure contracts are followed
  • Reporting potential cases to state and federal law enforcement and cooperate with fraud investigations
  • Pursuing the recovery of funds when fraud is suspected
  • Terminating contracts when fraud is confirmed

If you suspect fraud, report it. Call Delta Dental’s Anti-Fraud Hotline at 800–526-1852. Provide this number to your employees and encourage them to do the same. Callers may remain anonymous if they choose.

Customer service — reimagined

Customer satisfaction is about more than products. To ensure that customers are truly satisfied, the customer service they receive must be as outstanding as the product they purchase.

To take the customer service experience to a new level, we’ve introduced CX Reimagined, a training program that transforms the relationship between our customers and representatives, creating a transaction that’s more empathetic, intuitive and satisfying than ever before.

After two years of development, design and implementation, more than 1,000 full-time Delta Dental Customer Operations employees, including agents, supervisors and leaders, are scheduled to complete CX Reimagined by October 2021.

Putting the customer in customer service

Delta Dental’s customer service had been effective ­— in 2020, agents answered 12.7 million calls and resolved 99% of issues on the first call. It needed to be something more, though, said Ben Sieke, Director of Talent Development & Learning.

“Initially, our biggest goal was efficiency: Let’s take as many calls as we can as quickly as we can,” Sieke said. “But there was opportunity for us to look at this differently. Not to move away from running an efficient business, obviously, but instead to put the customer front and center. Every time somebody calls in, there’s an opportunity for us to delight them.”

Sieke said that while his team briefly considered purchasing training from an outside vendor, they quickly realized that the only way to ensure that this new set of customer service standards could be achieved was to design the training in house.

“We said, let’s create a custom Delta Dental learning experience for our people,” Sieke said. “CX Reimagined training is specifically for our employees, and it feels that way. It’s designed so that it feels real and relevant to their jobs.”

Answering the questions customers didn’t ask

One of the main focuses of CX Reimagined is to develop soft skills that enable agents to interact more effectively and personably with customers, said Earl Parker, Delta Dental’s Vice President of Customer Operations. These skills include empathy, active listening and de-escalation.

“Far too often, we want to jump in and solve without really understanding the issue,” Parker said. “So part of the training speaks to how you actively listen, how you affirm what you’ve heard to make sure that you’re going to answer and solve for the right thing.”

Another aspect of the training is teaching agents how to ask probing questions, questions that require more than a “yes” or “no” answer and help agents discover underlying or additional issues customers have.

“If our agents answered only the question that was asked of them, they would miss an opportunity to answer the bigger question, to solve the bigger issue, the customer has,” Sieke said. “Being a bit more empathetic and curious enables us to solve the whole problem at once.”

And these soft skills set Delta Dental’s service apart for the customer, Parker said.

“That’s viewed as by the customer as going above and beyond, not just servicing. And I think that’s important if we want to truly enhance the experience,” Parker said.

The results are in

While the intent to do better is there, one question looms large: Did it work? Did the training objectively improve the customer experience? Based on early results, the answer appear to be yes.

Customers rate Delta Dental’s customer service based on two sets of criteria:

  • Net Promoter Score (NPS), which is based on a zero-to-10 ranking of how likely customers are to recommend Delta Dental’s customer service to others
  • Customer Satisfaction Score (CSAT), where customers rank the service they received on a one-to-15 scale

Since CX Reimagined was launched in July 2020, both these metrics have improved substantially, according to a recent study on the training’s impact. Also encouraging was that a performance increase was seen in all employees.

“What’s interesting is that the most dramatic improvements were among the lower performers, the agents who were struggling,” Sieke said. “If you weren’t good at this and were lacking these skills, you acquired them in training and now you’re doing a great job.”

This is only the beginning

For CX Reimagined, the end of this phase is just the first step in an ongoing journey, Parker said.

Among the next steps he envisions are an annual refresher training for agents and doing more to help agents serve the broker and benefits administrator communities.

Analyzing customer data more closely to understand issues completely is another goal.

“For instance, if we find that members with a certain plan option are generally more dissatisfied than members who have other plan options, then we need to look at the data to understand what’s wrong,” Parker said. “That way we can fix it so those members are happier with the product.”

And making customers happier through expert, friendly, proactive customer service is the goal of CX Reimagined.

“We want our employees to be fully engaged in helping our members and providers navigate Delta Dental,” Parker said. “We want them to be fully engaged in providing easy experiences for members and providers, and we want them to be fully equipped to provide these experiences.”

Delta Dental gives access to healthy smiles in many languages

Language should never be a barrier when it comes to health care. If any of your employees have limited proficiency in English, direct them to Delta Dental’s Language Assistance Program (LAP). This service is free for members and perfect for employees who communicate in languages other than English to better understand their plans or even to communicate with their dentist.

The LAP offers a variety of language accessibility services, including:

  • The Delta Dental website in Spanish offers information on Delta Dental’s different plans, as well as articles jampacked with valuable wellness information.
  • Customer service is offered in 170 different languages. Simply call 866–530-9675 and request an interpreter.
  • Delta Dental’s online dentist directory is available in both Spanish and English and includes the languages spoken by dentists and staff members. This is a great tool for helping members find a dental office where their language is spoken.
  • In-person interpretation services are also available for dental visits. If a member cannot find a dentist who speaks their language, Delta Dental can arrange to have an interpreter present during their next appointment. In addition to non-English languages, American Sign Language interpretation can also be requested. All the member needs to do is contact Customer Service at least 72 hours in advance and make the request.
  • Document translation to any non-English language can be requested for any written materials, such as benefits information. Accessible formats like braille and audio files can also be requested.

If any of your employees are having trouble communicating with their dentist, call Delta Dental to arrange for a qualified interpreter to help via phone. 

Delta Dental telephone numbers for interpretive services: 

  • State Government Programs: 877–580-1042 
  • Delta Dental Premier®/Delta Dental PPO™: 888–335-8227 
  • DeltaCare® USA: 800–422-4234 
  • DeltaVision®: 888–963-6576 
  • TTY 711 

The new normal: hybrid workplaces

Over a year after non-essential workers quickly adapted to operating from home, a survey by PwC found that nearly 70% of executives believe that employees should return to the office three days a week while just 20% of employees agreed with that sentiment. In fact, that survey also found that 30% of employees would stay remote a full five days a week if allowed. Additionally, the New York Times found that just 25% of workers would prefer to go back to an office full-time. As COVID-19 restrictions continue to be lifted, the compromise for many offices has been hybrid work models. These models not only accommodate workers both remote and in the office as a means of safety, but have also become staples of employee satisfaction.

“Compromise,” however, is the key word. As hybrid work is new to much of today’s workforce, a learning curve is to be anticipated. Here’s what you need to know about the future of hybrid workplaces.

Why go hybrid?

In a post-pandemic world, only one thing is for certain: there is no “back to normal.” Many everyday practices have evolved to accommodate new health and safety protocols, including day-to-day office life. In a hybrid model, social distancing is made easier by having less people in the office, thereby minimizing the chance of a virus running rampant.

Going hybrid may also help companies save budget otherwise spent on office space. As of January 2021, demand for office leasing was down 61% from December 2019, according to Business Wire. As some businesses opt to let go of their leases, they might also choose to stagger in-office and work from home days for some teams to accommodate staff while maintaining less space.

While some companies may fear that this newfound flexibility could hurt productivity, research shows that it is simply not the case. A 2020 report by Microsoft found that 82% of the leaders they’d surveyed found their teams to be at least as productive working in their new remote environments as they had been in an office.

In addition to flexibility, other advantages include:

Disadvantages of remote work

As many workers have now experienced, not every aspect of remote working is a positive. While the hybrid model might help remedy some of the disadvantages, there are still some concerns:

  • Burnout. Perhaps you’ve heard of, or even experienced, “Zoom fatigue” — the physical and mental exhaustion brought on by too many video conferences. Screen burnout is very real. In a hybrid work culture, time spent with your team truly face-to-face may help relieve that draining feeling associated with spending hours meeting virtually.
  • Company culture. One disadvantage of working from home cited repeatedly through the pandemic was the feeling that company culture and values are harder to upkeep virtually. Bringing workers back to the office a few times a week may help create physical reminders of the company mission.
  • Reliance on technology. Technology is not infallible. There are internet outages, security risks and keyboards accidentally taken out with a spilled water bottle. When a single laptop is your only means to get the job done, there’s a lot riding on a little piece of technology.

Considerations for employers

With so much uncertainty about what the next year holds, flexibility and adaptability in the workplace is an important consideration for all employers. According to the Society for Human Resources Management, these are a few of the questions that company leaders should ask themselves when considering a hybrid workplace:

  • Why does a specific employee need to perform his or her work in the office?
  • To what extent does an employee need to collaborate with others?
  • How is someone feeling about working from home versus in the office?
  • Is that person feeling disconnected or overwhelmed?
  • Is the employee clear about the organization’s strategy and his or her role and responsibilities?
  • What types of meetings are best to hold in person?

Perhaps the largest lesson for employers from all of this is that employee safety should always be at the forefront. Whether employees spend their days at home or in the office, keeping them viable, healthy and happy is a victory in and of itself.

Kids’ unmet oral health needs highlighted by the pandemic

When your employees become parents, they receive an onslaught of information about their child’s growth markers and health checkups from immunizations to well-child visits. When it comes to dental care, however, less than half of parents receive professional advice on when to start taking their child to the dentist.

And lack of guidance is only the beginning of the problem. Access to dental care has been an ongoing challenge for U.S. children, but during the pandemic, dental care emerged as children’s greatest unmet health need, according to a recent study published in JADA.

What does this mean for your employees and their children, and what can you do to support them?

The pandemic’s effect on pediatric oral health

Even before the COVID-19 pandemic, dental disease among children was rampant:

The pandemic made these problems worse by stressing the financial systems that delivers dental care with income and job losses. Households were three times more likely to identify dental care as an unmet health need as a result of the pandemic compared to medical care, according to a JADA study. The authors found a significant association between the probability of unmet child dental care and pandemic-related household income or job loss.

About 40% of families reported the loss of a job or decrease in income due to the pandemic. Before the pandemic, children from families with lower income or who were on Medicaid were twice as likely to have cavities than children from higher-income households. Whether due to lost or decreased income, fear of contracting COVID-19 and mixed communication from health organizations, dental care visits dropped in 2020.

Many people were able to stay covered for medical procedures due to robust signups for Medicare and Medicaid pandemic. But cost remains the major barrier to receiving dental care, since Medicare and Medicaid packages rarely cover many dental procedures. Although access to pediatric dental care has grown for families with public insurance since the early 2000s, kids in low-income families are still less likely to visit the dentist regularly. Additional barriers include difficulty finding a willing dentist, transportation and geographic proximity to dental providers.

Potential solutions for children’s unmet oral health needs

As a benefit administrator, you can invest time into communication efforts that may bridge knowledge gaps among your employees. Here are a couple of ways you can get started:

  • Talk about timelines. Inform your employees about recommended timelines for pediatric care to guarantee they get the information they need, whether or not their dentists communicate that information.
  • Design your package. When you’re designing your benefits package, cover important preventive services for kids, like sealants and fluoride treatments.
  • Highlight plan features. Encourage employees to take advantage of aspects of their insurance, like teledentistry coverage, that can make pediatric care easier. Did you know that 75% of pediatric dentists offer virtual services, compared to only a third of general dentists?
  • Share materials. Explore Delta Dental’s wellness resources and share a selection of helpful articles and flyers in an email or on an internal site. You can even highlight assets that are made for kids, like MySmileKids and Grin! for Kids.
  • Be consistent. When communicating helpful information to your employees, using multiple channels can be confusing and difficult to keep track of. Find a simple routine for sharing, like posting information on an internal webpage with monthly or quarterly email notifications, so that your employees always know where to look.

How Delta Dental invests in communities

To help dentists make investments in their communities, the Delta Dental Community Care Foundation awards several million dollars in grants each year to increase access to care. These awards enable underserved individuals, including children, to get preventive and restorative treatments in accessible locations. More than 250 organizations received funding from the Delta Dental Community Care Foundation during the COVID-19 pandemic, totaling $11 million to provide relief. Many of these clinics support and serve children.

These Access to Care grants fund activities designed to remove barriers to seeking care such as distance, cost, and even fear. The grants can be used to set up mobile or pop-up clinics in a local community, provide dental care in underserved clinical settings, fund outreach programs or offset costs for clinics that routinely provide care to underserved populations.

What comes next

There will probably be some relief for underserved communities, including children, soon. The U.S. economy seems to be recovering. The national unemployment rate is projected to fall to 5.3% by the end of the year.

But the problems highlighted by the pandemic shouldn’t be ignored. As a benefits administrator, you can’t be expected to fix all of the problems in the American economy or health care industry. Still, by highlighting resources and keeping your employees informed, you can positively affect the employees you work with and their children.

Does gum disease affect blood pressure?

May is National High Blood Pressure Education Month, and your employees need to be aware of the risks of hypertension and how to keep blood pressure under control. During their dental visits, employees can monitor their status through blood pressure checks.

The causal link between gum disease and hypertension

Patients with periodontitis and no other health issues are twice as likely to have elevated blood pressure as those with healthy gums, according to a March 2021 research study. Periodontal bacteria can trigger an inflammatory response that affects blood vessel function and lead to the development of hypertension.

Before a Delta Dental dentist starts an exam, a blood pressure check can reveal issues beyond oral health. Patients with gum disease may be at higher risk for hypertension, due to bacteria. Research has found a correlation between oral bacteria and plaque buildup in arteries.

A normal blood pressure reading is less than 120 mm Hg systolic and less than 80 mm Hg diastolic, according to Centers for Disease Control and Prevention guidelines. Your employee should be concerned if the systolic/diastolic reading falls into one of these categories:

  • Elevated: 120–129 mm Hg and less than 80 mm Hg
  • Stage 1 Hypertension: 130–139 mm Hg or 80–89 mm Hg
  • Stage 2 Hypertension: >140 mm Hg or > 90 mm Hg

Hypertension can put your employees at risk for heart disease and stroke, the leading causes of death in the U.S. Nearly half (45%) the adults in the U.S. have hypertension or are taking medication to control it, and 24% of them have it under control. 

The dangers of gum disease

Gum disease triggers inflammation that thickens the lining of blood vessels. The thickening plaques decrease blood flow, which increases the risk of heart disease and stroke.

Patients with healthier gums had lower blood pressure and responded better to medications, compared to those with periodontitis, according to an analysis, published in Hypertension, based on review of medical and dental exam records of more than 3,600 people with high blood pressure.

What’s more, periodontal therapy can make a difference. Intensive periodontal treatment lowered blood pressure levels (12.67 mm Hg/9.65 mm Hg) in patients over six months, after a four-week intervention, according to a clinical study published in 2017 in the Journal of Periodontology.

During an office visit, the dentist can check blood pressure and alert the employee to risks if the reading is elevated. This first-line screening can ensure proper medical treatment can be given.

Educating your employees

As a benefits administrator, you can promote for blood pressure control awareness and healthy habits to your employees to help prevent serious health issues. In addition to adequate nutrition, exercise and sleep, you can emphasize the importance of regular checkups by health care providers.

You can encourage employees to take a quiz to determine their gum disease risk. Delta Dental dentists can explain how keeping gums healthy can contribute to better circulation and heart function through lowering blood pressure.

For employees with heart disease, you can offer SmileWay Wellness Benefits to give them incentives for keeping it under control. Their periodontal treatment and advice on daily flossing and brushing regimens add value to your employees’ plan, not only for oral health but also for heart health.

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