Insider Update

Broker 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 clients. It drives up the cost of coverage for your clients and their 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 your clients to instruct their 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. Ask clients to let their 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. Encourage clients 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 your clients

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 your clients’ employees can keep in mind as they choose their dentists.

  • 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.
  • 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.
  • Ask dentists if they have written anti-fraud policies and if their office staff has read and signed these policies.

To help clients’ companies avoid fraud, you can also:

  • Refer clients to the “Fight Fraud” flyer (PDF) as an educational aid
  • Encourage clients to implement a clearly defined anti-fraud policy and have employees sign it
  • Encourage clients to 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 clients and encourage them to do the same. Callers may remain anonymous if they choose.

Track your success with our broker rewards dashboard

If you sell our small business plans, here’s a tool that can help you shine! The small business rewards program dashboard for brokers has everything you need to take full advantage of our broker rewards program.

Retention information

Some of the dashboard’s helpful features include:

  • Your rewards program earnings
  • Your bonus level status
  • Targets that show you how many new sales you need to reach the next bonus level
  • New sales and persistency bonus status summaries
  • Active groups retention counts
  • Total groups year-to-date, including new and existing groups
  • A downloadable report
  • Rewards program eligibility rules and requirements
New sales information

And if you need support, it’s available via email or phone at 866–760-4080.

To take advantage of all the dashboard has to offer, register today. The process is simple. All you need to get started is a few pieces of information:

  • Your name
  • Agency name
  • Email address
  • Social Security or individual taxpayer identification number

After you’ve entered the required information and we’ve located your broker account, we’ll send you a validation email to complete your registration. Note that you may not be able to access the dashboard directly if your agency is the legal entity receiving commissions rather than you.

For questions about the dashboard or the broker rewards program, please contact your Delta Dental sales account executive. Interested in selling to small business? Learn more about our Small Business Program.

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.”

Clients rate Delta Dental’s onboarding process outstanding

The Delta Dental onboarding process is smooth sailing, according to new clients. According to the results of a recent survey, most new Delta Dental group clients found their onboarding experience to be exceptional.

Among more than 200 new clients who completed the survey, 98% rated Delta Dental’s Customer Onboarding team as very good or excellent. Also noteworthy is that the Customer Onboarding team didn’t receive a single negative review.

In the survey, clients were asked to rate the service they received from their Onboarding Project Manager based on these criteria:

  • Provided oversight on end-to-end setup to ensure the project stayed on track and overall client satisfaction was met
  • Provided timely response and follow-up to client phone calls and emails
  • Was knowledgeable about the client’s benefit plan
  • Communicated potential problems quickly
  • Provided service that met the client’s expectations

“The survey speaks volumes to the client’s experience during implementation,” said Christina Snyder, Delta Dental’s Director of Client Onboarding. “One of a new client’s biggest fears when moving carriers is the onboarding process and all the headache that can arise. We understand that, and that’s why we’ve been developing our onboarding process for over a decade.”

The Customer Onboarding team acts as the project management expert throughout the onboarding process. Each new client is assigned an Onboarding Project Manager, who leads external and internal teams through requirement sessions, documenting client expectations and managing the timeline and milestones. The Onboarding Project Manager also identifies, communicates and mitigates risks.

Snyder said that the Onboarding Project Manager’s goal is to ensure that timing and accuracy expectations are not only met but exceeded: “They’re the client champion throughout the implementation.”

Each new client is also provided an online client dashboard. The dashboard provides instant access to vital information, including:

  • Real-time timeline and requirements
  • Minutes and action items
  • A contact list
  • Benefits administrator documents
  • Online training sessions and demos
  • A client feedback survey

So remember, for your group clients, a stellar onboarding experience is just one more example of the excellent value and customer service your clients get with a Delta Dental plan.

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 clients 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.
  • In-person interpretation services are also available for dental visits. If a member can’t 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. Accessible document formats like braille and audio files can also be requested.

If any of your clients 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 

What drives buyers of individual Delta Dental plans?

As you’re probably well aware, attracting new clients and pinpointing their needs can be challenging. To help you, Delta Dental recently explored the characteristics of people who buy individual dental plans.

PPO versus DHMO dental plans: What’s the difference?

A PPO plan, or fee-for-service plan, is a network-based plan in which enrollees can visit any licensed dentist, although they’ll save more by visiting an in-network dentist. These plans usually have annual deductibles and plan maximums.

A DHMO plan is a prepaid dental benefits product in which enrollees usually must visit their selected primary care general dentist to receive benefits. These plans have no annual deductibles or plan maximums — enrollees pay a fixed copayment amount for covered procedures.

Who buys individual dental insurance?

Anyone who has either had an employer-sponsored dental plan or bought an individual dental plan in the past is a potential client. Even clients who currently have individual dental insurance may be willing to change or update their coverage to get better rates or richer benefits.

DHMO buyers are more likely than PPO buyers to be switching from one individual dental plan to another. PPO buyers are usually transitioning to an individual plan from employer-based group dental coverage. Not surprisingly, the most common reason for this is because they retired from a job and lost their coverage.

What are some major drivers for dental insurance buyers?

Clients shopping for individual dental insurance obviously care about their dental health. That’s why for both PPO and DMHO buyers, having coverage for preventive care and being able to maintain the appearance of their teeth are the two most important factors in their decision to buy.

For PPO buyers, key factors include a dentist network that allows them to keep their current dentist. Consider suggesting plans that offer a large dentist network, which increases the likelihood that their dentist participates in the plan. PPO buyers also like to stick with what they know — we find that familiarity with a brand is an important factor in choosing a dental plan.

Among DHMO buyers, cost and value are more important. Key factors for purchase include low out-of-pocket costs, lowest price and the best coverage for the price.

Income may help you determine which products to consider for your clients. For clients with higher incomes, consider PPO plans, because we’ve found that these clients usually want the flexibility to see the dentist of their choice. Brand recognition is also important.

For clients who earn less, a DHMO plan may be a better option. Both cost and the ability to meet dental care needs are important to these clients, so knowing ahead of time how much a procedure will cost — and being able to plan and prioritize care accordingly — could be a plus.

For all clients, consider bundling offerings. Dental insurance buyers may also be interested in medical and vision insurance. However, they tend to be less interested in other types of insurance, such as life, disability, accident or pet insurance.

How do buyers like to shop?

According to a recent survey, the broker channel is a preferred method among American insurance buyers, with 43% selecting a broker or agent as a favorite option. That rate was higher among baby boomer and Generation X buyers, 61% of whom purchased insurance from a broker. Among millennials, 23% said they used an agent or broker to buy insurance.

The most popular shopping method overall was online, and most of the buyers surveyed said they used more than one channel to shop.

Among the most influential factors when shopping were an easy application process, followed by trust in the brand.

Is there anything else about buyers that I should be aware of?

Our research indicates that all buyers have a similar perception about value of dental insurance. They believe that dental insurance saves money on unexpected costs and makes visiting a dentist more affordable. Both direct PPO and DHMO buyers agree — dental insurance is a smart financial choice.

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