Updated March 25 at 6:26pm
health insurance

Delta Dental fined $25K for claims’ process


CRANSTON – Delta Dental of Rhode Island was fined $25,000 after a review of the dental insurer’s claims process found that it was not in compliance with some of the state’s laws and regulations.

The comprehensive review of Delta’s claims process began on May 14, 2010, in response to 23 complaints from patients and dentists received by the state Office of the Health Insurance Commissioner.

The completed report was dated June 24, 2011. A response was filed by Delta Dental on July 29, 2011. Delta Dental also filed two requests for reconsideration, in August 2011 and a second time in September 2011.

The 52-page report was conducted by Charles C. DeWeese of DeWeese Consulting Inc., Linda Johnson of Johnson & Associates, and John Aloysius Cogan Jr. It made 19 specific recommendations, based on what it found to be problems with the way that Dental Dental of Rhode Island processed claims.

Among the key report findings were recommendations for change in Dental Dental policies:

  • Delta Dental should institute processes to record and act on all complaints, whether written or verbal.

  • Delta Dental should discontinue use of the utilization management program as its primary mechanism to address poor quality care. A quality management program should incorporate a process to address substandard care to protect members from providers that insurer has identified as providing poor quality care.

  • Delta Dental should institute a study of its claims denials to determine the reasons for the high rate of overturn on appeal.

In his revised final order, dated Jan. 23, 2012, Koller removed two of the 19 recommendations.

“I appreciate the seriousness with which Delta Dental has taken this examination and its findings, and its commitment to fully implement the recommendations of the Examination Report,” Koller said. He said he was “confident” that Delta Dental’s board of directors and its management will work together to monitor implementation of the recommendations and improve the dental insurer’s compliance with the statutes.

Delta Dental is dental health insurer authorized to operate as a nonprofit dental service corporation in Rhode Island. According to the report, as of Oct. 31, 2010, Delta Dental reported having 287,418 members in premium groups and 615,505 members in all groups, in 4,050 total accounts. Among its accounts were 1,800 individual Chamber of Commerce accounts. Delta Dental also covered many out of state employees of Rhode Island employers, particularly employees of its largest group customer, CVS Caremark.

In a July 29, 2011, letter Herbert W. Olson, the legal counsel for OHIC, Kathryn M. Shanley, Delta Dental’s Vice President of External Affairs, wrote: “In 2010, our organization processed nearly 1.6 million claims and pre-treatment estimates an issued claims totaling $170 million to over 30,000 providers all across the country. Approximately 50 percent of our claims/payments were for services rendered by Rhode Island dentists. It is unavoidable when handling such a large volume of claims that some errors are made and it is also inevitable that some claim decisions, particularly denials, result in dissatisfied dentists and members. We strive to minimize dissatisfaction and to respond appropriately to complaints, but we can always learn from our mistakes and work to improve out performance.”


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