Benefits administrator blog from Delta Dental

Author: Delta Dental (Page 1 of 29)

How high out-of-network reimbursement could be hurting your employees

When it comes to designing your Delta Dental PPO™ plan, it can be difficult to find the balance between what employees want and what’s most cost-effective for your group. You may think that allowing for high out-of-network reimbursement will keep your employees happy. But high out-of-network reimbursement could actually be hurting them in unexpected ways.

What is out-of-network utilization?

Out-of-network utilization is when your covered employees visit dentists who aren’t in Delta Dental’s networks. It may seem trivial, but when a high percentage of your employees start receiving care outside of their network, there can be unexpected consequences. On an individual level, your enrolled employees may experience higher costs and miss out on quality guarantees, and high out-of-network utilization can make plans more generally expensive to account for the higher cost of care.

What is out-of-network reimbursement?

Reimbursement is the amount that your plan bases its payment on, also known as the maximum plan allowance. This is separate from the percentage at which certain services are covered.

Under most PPO plans, Delta Dental PPO dentists are reimbursed at PPO fees, and Delta Dental Premier® dentists are reimbursed at Premier or PPO fees. Reimbursement for non–Delta Dental dentists varies by plan. Paying non–Delta Dental dentists based on the 80th percentile or above is considered high reimbursement.

Percentiles are calculated by ranking a set of given fees from lowest to highest. On a list of 10 given fees, the eighth ranked fee would be considered the 80th percentile. There isn’t a set amount of space between percentiles, meaning that some percentiles may have the same fees.

In this simplified example, the 80th percentile is $27 and the 50th, 60th and 70th percentile are all $25. At the 80th percentile, 80% of dentists’ fees are paid as billed. Dentists whose fees are above this percentile are charging more than most dentists in their market.

Dr. A10$20
Dr. B20$20
Dr. C30$23
Dr. D40$24
Dr. E50$25
Dr. F60$25
Dr. G70$25
Dr. H80$27
Dr. I90$30
Dr. J100$35

How high out-of-network reimbursement drives up costs

Reimbursement rates are customizable by plan, dependent on your employees’ needs. But having high reimbursement rates for out-of-network dentists can bump up costs across the board. Non–Delta Dental dentists can set their prices wherever they want without being subject to contractual obligations. This not only allows them to charge higher prices but also discourages Delta Dental dentists from staying in network.

Example: the difference between in-network and out-of-network dentist costs

To illustrate, let’s assume the PPO contracted fee for a procedure is $1,000. If your plan covers that procedure at 50%, one of your employees visiting a PPO dentist would only need to pay $300, and your plan would pay the other $300. For the same procedure, an out-of-network dentist could cost your employee $538.

If your plan’s reimbursement for out-of-network dentists is based on the 90th percentile (which, let’s say, amounts to $925), your plan would pay 50% of $925, or $463. Your employee would pay $538.

Delta Dental PPO dentistNon–Delta Dental dentist
Dentist charges$1,000$1,000
Accepted fee$600$1,000
Reimbursement allowed by plan (MPA)$600$925
Reimbursement based onPPO fee90th percentile
Delta Dental plan pays
(50% of maximum plan allowance)
Member pays
(Difference between “accepted fee” and “Delta Dental plan pays”)
Plan savings
(Difference between “dentist charges” and MPA)
This table is for illustrative purposes only. 

Not only do your employees who go out of network pay more at the time of service, they also run the risk of hitting their annual plan maximum much more quickly. In the long term, a plan with a high rate of out-of-network utilization may also drive up premium costs by increasing claim expenses.

What’s more, high out-of-network reimbursement lowers the incentive for dentists to join or stay in Delta Dental’s networks. By staying out of our networks, dentists can charge higher prices and avoid quality monitoring like credential checks and in-person audits.

Ultimately, your employees don’t benefit from high out-of-network reimbursement.

Why should your employees visit Delta Dental dentists?

While choosing an in-network primary care physician has become almost routine, many people seeking dental care are less aware of the value of choosing an in-network dentist and the disadvantage of visiting an out-of-network dentist.

Avoid inconvenient charges

When your employees choose to visit a non–Delta Dental dentist, they run the risk of being balance billed. That means their dentist may charge them more than the maximum plan allowance, and they’ll need to foot the rest of the bill. Delta Dental can’t predict enrollees’ out-of-pocket costs when they go out of network.

Since out-of-network dentists aren’t always paid directly by Delta Dental, your employees will typically be charged the full price of a procedure upfront, even if their coinsurance is less than the full price. After paying at the dentist’s office and submitting a claim to Delta Dental, they’ll receive a check in the mail for the portion of their procedure’s cost that’s covered by their plan.

When your employees visit a Delta Dental dentist, they’ll only be expected to pay their share and they won’t need to submit claims.

Guarantee of quality care

To participate in a Delta Dental network, dentists are held to high standards to ensure they provide consistent, quality care to their patients. These standards include:

  • Rigorous credential checks. Delta Dental dentists must be legally credentialed and must submit their credentials to Delta Dental for verification every three years.
  • Quality management program. Delta Dental dentists may be subject to onsite audits to assess hours and availability, treatment outcomes, facility and equipment, infection control, documentation and more. Dentists who perform poorly in audits are put on improvement plans and may be dismissed from our network if quality concerns are not addressed after improvement programs are completed.

When your employees visit non–Delta Dental dentists, we cannot guarantee that the practice meets Delta Dental’s rigorous credentialing and safety standards. Since these dentists are out of network, we have no mechanism to ensure they provide quality care and services to our members.

How to promote in-network visits

Luckily, there are a few things you can do to help your employees get the care they deserve.

Educate your employees on the advantages of staying in network

The easiest way you can help today is by educating your group about the advantages of in-network dentists. Delta Dental has materials about the importance of staying in-network that are ready for you to share with your employees, including flyers and videos:

There are also more specific, customizable flyers available for request through your sales contacts.

Create plan incentives for staying in network

To encourage in-network visits long term, work with your Delta Dental Sales representative to build incentives into your plan design that encourage visiting in-network dentists.

For example, these options (not available in all states) can help boost in-network utilization:

  • Maximum and deductible network differentials. Reward employees who stay in network with a higher maximum and lower (or no) deductible for in-network visits. If your plan includes maximum or deductible waivers for diagnostic and preventive services (D&P), consider setting these up to apply only when members choose an in-network dentist.
  • Greater coverage levels for in-network services. For example, you might cover a specific benefit at 80% at a Delta Dental dentist and 60% out of network.

Reevaluate your plan’s reimbursement levels

Talk to your Delta Dental Sales representative about updating your plan’s reimbursement levels to encourage employees to choose an in-network dentist. If your plan reimburses non–Delta Dental dentists at a high level, such as the 80th percentile, your representative can help you determine the appropriate level to meet your group’s needs. 

By visiting Delta Dental network dentists, your employees receive the predictable, quality care that they deserve. Set up a meeting with your Sales representative today to develop a plan to encourage your employees to choose a network dentist.

Note: This post was updated to clarify the illustrative example.

Get ready for open enrollment

It’s getting close to open enrollment, and that means you’ll be fielding questions from employees who are trying to choose their benefits for the coming year. Luckily, Delta Dental has your back. You can find everything you need to answer those questions and help your employees make informed decisions.

Gather your materials

One of the best sites of information available to you is Delta Dental’s open enrollment resources page. It features many flyers on the basics of our plans, our network of dentists and how to use our plans. You can download this information and either print it or send it out electronically to your employees.

Discuss with your Delta Dental representative to determine what core flyers you need. Sending out flyers electronically is the best way to distribute the information, but we do have a limited number of flyers available for print. Be sure to get your orders in sooner rather than later.

An FAQ page for benefit administrators may answer many of the questions you may get from employees about Delta Dental’s plans.

Members can access information online and print an ID card, learn about our plans and explore online tools. Videos that explain the major plans are available, as well as Spanish versions.

Go virtual

In the wake of the pandemic, you may find that virtual benefits fairs work well, especially if your employees work remotely. Contact your Delta Dental representative to set up a virtual booth session, which is a way for employees who can’t make it into the office to talk with us online and get information about the various plans we offer. (If you want a virtual booth session, you need at least 100 attendees.) 

Delta Dental reps can also appear in person at your benefits fairs if you have 100 people attending. Contact your representative for more details.

Start early

Aside from giving your employees information, what else can you do? Preparation is key. Brainstorm to find innovative ways to make open enrollment engaging and informative, motivating them to choose an insurance provider.

If you’re hosting a benefits fair, motivate your employees to participate through a themed event, or raffle off prizes for attending. Send out emails with electronic flyers attached, and highlight any changes to employee benefits.

Your Delta Dental representative is available to help you with ideas on how to prepare for open enrollment. Start soon, though: Open enrollment will be here before you know it.

Goodbye OBR, hello eBillPay

Your billing and invoicing experience is about to get a whole lot better with eBillPay, our brand-new invoice and payment management site for benefits administrators. The new site is custom built specifically to meet your needs, based on your feedback.

New and improved features

eBillPay provides you with not only a modern look and feel but also easier navigation and a more user-friendly design than our previous platform. Our goal is to provide you with the best customer experience for your billing and invoicing needs, including:

  • Ability to make payments at no cost through the application
  • New user-friendly invoice filter, export and presentment options to help be more efficient and analyze data more effectively
  • An easier line-item adjustment process, with the ability to edit or delete adjustments
  • Payment search capability with no waiting period to view payments made
  • The ability to manage your email preferences for invoice availability and payment confirmation

Have questions? We can help

If you have questions about how to use eBillPay, relax ― we’ve got you covered! Refer to this helpful how-to video or check out the eBillPay FAQ for answers to commonly asked questions about the system. If you still have questions or want to find out more about eBillPay, feel free to contact us at

Send kids back to school with a smile

The COVID-19 pandemic has likely been hard on you and your employees. But it’s also been hard on their children, particularly their teeth. In fact, dental care was children’s No. 1 unmet health care need during the pandemic, according to a study in the Journal of the American Dental Association.

Let’s meet that need! With children returning to school, now’s the perfect time to help ensure that your employees’ kids get the dental care they need.

Kid-friendly coverage

Delta Dental covers the dental services your employees’ children need for strong, healthy teeth.


Sealants help protect children’s permanent teeth by covering them with a thin plastic coating. Sealants are a very effective way to combat tooth decay, preventing 80% of cavities for two years and continuing to protect teeth for up to four years. Sealants are most effective when applied to permanent teeth soon after they emerge.

Most of our plans cover dental sealants for children, which means your employees can often get their kids protective sealants at little or no out-of-pocket cost. All standard DeltaCare® USA plans cover sealants. Sealants are also a standard benefit in group Delta Dental PPO™ plans, although coverage for sealants can vary by policy.

If your plan covers sealants, you can use this helpful flyer to educate employees about this procedure.

Fluoride treatment

Fluoride treatment, also known as topical fluoride or fluoride varnish, is a common procedure for children to help strengthen enamel and prevent tooth decay. This service typically has an age limitation, which can vary by plan.

If your plan covers this preventive service, share this flyer about fluoride treatment to help parents understand what it is and why it matters for their kids’ dental health.


The preteen and teenage years are the most popular time for orthodontic treatment, such retainers and braces.

Orthodontic coverage is available under both Delta Dental PPO and DeltaCare USA plans. In fact, our plans can help cut the cost of braces in half, which is why we were recently recognized as the best overall dental insurance for braces.

All DeltaCare USA plans cover orthodontics at set copayments with no maximums or deductibles, and you can choose to add orthodontics to any Delta Dental PPO plan.

Wellness resources you can share

Help your employees and their kids get ready for a healthy school year with these helpful resources.

Back-to-school resources

Send your employees our back-to-school resources, including articles and recipes to promote children’s dental health. Post the link on your intranet, include it in an internal newsletter or click the “Share” button at the top of the page to send it to employees by email.

Looking for a quick PDF to attach to an email or print and post in a break room? Check out our back-to-school dental tips in flyer form.

Wellness library

You can find easy-to-share articles about kids’ and teens’ dental health in Delta Dental’s online wellness library, including back-to-school tips, a guide to healthy dental habits for kids and dental health advice for teens.

You can also share healthy recipes kids will love and informative videos on topics from teething trouble through caring for teeth with braces. 

Got Spanish-speaking employees? Articles, recipes and videos are also available in Spanish.

Grin! for Kids

Grin! for Kids is a free, full-color activity book that covers a variety of dental health topics in a fun and interactive way for children in kindergarten through fifth grade. Your employees’ kids will love the games, puzzles, jokes, coloring pages and more. You or your employees can download and print the latest version and browse back issues for more games and activities. This publication is available in both English and Spanish.

Dual choice: the best of both worlds

None of your company’s employees are quite the same. Some are young and single, some have partners and families, some are approaching retirement. Some have excellent dental health and some, well, don’t. With so many different situations and stages of life, you might ask yourself if a single dental plan can truly meet all their needs.

Fortunately, you have a choice. More precisely, a dual choice ― Delta Dental’s dual choice. This plan configuration allows you to offer the attractive benefits, large network and substantial discounts of a Delta Dental PPO™ plan while also offering the predictability, affordability and simplicity of a DeltaCare® USA HMO-type plan.

How does it work?

As the name suggests, when an employer offers dual choice, employees have the freedom to select between either a PPO or HMO-type plan. With this flexibility, employees can decide for themselves which plan is the best fit, and can switch from one plan to another during open enrollment if they change their mind.

I’m still not sure my employees really need more than one plan type. What are some other factors to consider?

Here are a few reasons your employees might prefer one plan to the other.

 Delta Dental PPODeltaCare USA
AvailabilityDelta Dental’s expansive dentist network combined with the freedom to see any dentist means that employees who select a Delta Dental PPO plan will be able to find a dentist wherever they are, and almost always be able to find one who’s in network.Employees who chose a DeltaCare USA plan must visit their selected primary care dentist. For employees who live in rural or remote areas, being required to stay in the DeltaCare USA network could make finding an in-network dentist difficult.
Choice of dentistsEmployees who choose a Delta Dental PPO plan can see any licensed dentist, which might be important to employees who don’t want to switch from a favorite dentist.DeltaCare USA members must select a primary care dentist from the network. 
ConvenienceA Delta Dental PPO plan allows employees to visit any licensed dentist, regardless of network.DeltaCare USA members must visit their selected dentist, which means that employees may have to schedule time off and drive a significant distance if their dentist isn’t located close to where they’re working.
CostFor employees who need costly dental work, the substantial network discounts on services a PPO plan offers might make the additional expense worth it. For employees, DeltaCare USA plans are usually significantly less expensive than Delta Dental PPO plans. Orthodontics is always covered and often cheaper under DeltaCare USA, which is a plus for families with teens or preteens. These plans also have no maximums.
OrthodonticsNot all PPO plans cover orthodontics, and all have a lifetime orthodontic maximum. All DeltaCare USA plans cover orthodontic treatment. Treatment is covered at a set copayment for children and adults, with no deductibles, maximums or lifetime maximums. These plans also have no limits on the number of courses treatment that a member can have. So if an employee who has already had a full course of orthodontic treatment needs another, the plan will cover the second treatment.
Pediatric dentistryChildren who are covered under Delta Dental PPO plans can visit any pediatric dentist, and there’s no age limit beyond the cutoff set by the pediatric dentist. DeltaCare USA members can’t choose a pediatric dentist as a primary care dentist. Under these plans, pediatric dentists are considered specialists who must be referred by their selected dentist, like with any other specialty care. Pediatric care is also covered only up to age 8; after that, the child must visit a DeltaCare USA general dentist.
SimplicityDelta Dental PPO plans have deductibles and annual maximums. Some services may also have lifetime maximums. Out-of-pocket costs may vary depending whether the dentist is in network.DeltaCare USA plans have no deductibles or maximums. They also provide employees with a list of included procedures and their copayments, so they’ll know exactly what their out-of-pocket costs will be. This makes planning and budgeting treatment easy.

OK, but will offering a dual choice plan create a lot of paperwork and headaches for me?

Relax ― administration is painless!

For more information about dual choice, contact your account manager. To help your employees learn more about dual choice, here’s a useful flyer you can share and a pair of videos that explain each type of plan. You can also refer employees to this helpful site for more information about their plans.

Virtual dentistry helps employees get the most out of dental coverage

Teledentistry became popular in the early days of the COVID-19 pandemic, but even as businesses and workplaces have reopened, it remains relevant to employees and businesses alike.

The ability to receive a remote dental evaluation is a valuable benefit for employees who might otherwise not use their diagnostic benefits.

What is teledentistry?

Teledentistry, also known as virtual dentistry, is when a dentist performs a consultation via phone, text or video to diagnose dental issues, offer care advice and determine appropriate treatment, which may include a prescription or in-person follow-up visit.

Teledentistry appointments can be synchronous, such as a video call when the dentist and patient are interacting with each other in real-time, or asynchronous, such as when the patient sends a video or photo of their issue to the dentist and receives a reply later.

What teledentistry resources does Delta Dental offer?

  • Toothpic is a photo-based teledentistry platform that offers a virtual dental assessment from a Delta Dental dentist. Employees answer questions about their oral health history and the reason for their visit. Toothpic will help employees take photos of their mouth, which will be sent securely to a Delta Dental dentist for review. In less than 24 hours, employees will receive a comprehensive diagnostic report with their results, treatment options and cost estimates.
  • Delta Dental – Virtual Consult connects Delta Dental members and dentists for real-time video appointments. It’s totally secure and HIPAA-compliant. Virtual Consult makes it easy for employees to connect with a dentist in real time to get virtual consultations, e‑prescriptions and check-ins.

Do employees need special equipment for teledentistry appointments?

Beyond an internet-connected computer or mobile device with a camera, no special equipment is required for teledentistry appointments.

Why would employees want to use teledentistry if they can visit the dentist in person?

Teledentistry appointments can be a convenient way for employees to fit dental care into otherwise busy schedules. Instead of having to take time off work for traveling to and from the dental office, they can simply schedule a teledentistry appointment at their convenience. They can also use teledentistry appointments when they’re feeling ill or don’t wish to travel to the dentist’s office, when issues arise while they’re out of town away from their usual dentist, or when they want an expert opinion outside of regular office hours.

Is teledentistry covered by my company’s Delta Dental plans?

Generally, yes. For Delta Dental PPO™ plans that cover diagnostic and preventive (D&P) services at 100%, teledentistry appointments simply count as a regular exam. For plans that cover these appointments at less than 100%, the Toothpic platform will automatically prorate the cost of appointments accordingly.

And for plans that don’t offer copays for D&P services instead of coinsurance (including DeltaCare® USA), teledentistry appointments are available at a low flat rate.

Where can I get more information about teledentistry services for my employees?

To promote these resources to your employees, download the Toothpic and Virtual Consult flyers under Value-added features.

Employees can also learn more about virtual dentistry on our website, and sign up for Toothpic and Virtual Consult online.

« Older posts

© 2022 Word of Mouth

Theme by Anders NorenUp ↑