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If you're like most Delta Dental
subscribers, you probably leave it to your dentist to
submit your Delta Dental claim. It's very important to
make sure that those claims accurately identify the
services provided and fees charged.
Under New Jersey and federal law,
misrepresentations on claim forms are considered fraud
if they are intentional and material to the claim. That
includes failure to disclose waiver of all or part of
your co-payment responsibility.
The amount of your co-payment and
terms of your benefits are determined by the contract
between Delta Dental and your organization. Co-payments
serve to make patients aware of the costs of healthcare.
They also prompt patients to use their benefits wisely
and seek out dentists who participate with Delta Dental
Plan of New Jersey, in order to maximize their benefits.
If your dentist waives your
co-payment, without disclosing his or her intention on
the claim submitted to Delta Dental, then the actual fee
charged is lower than the fee submitted. For example, if
a claim is submitted for $100, and Delta Dental Plan of
New Jersey pays the claim at 80% or $80, but the doctor
"forgives" the co-pay, then the actual fee
charged is $80 and Delta Dental should only pay $64.
The undisclosed waiving of
co-payments could be used by dentists to create unfair
competition or as an inducement to attract new patients.
Delta Dental Plan of New Jersey does not prohibit
dentists from offering discounts; however the discounted
fee must be indicated on the claim form.
Submitting a fee higher than the
fee the dentist actually intends to collect constitutes
"overbilling." This applies to the undisclosed
waiver of co-payment as well as undisclosed discounts.
Dentists must disclose all waivers of co-payment and/or
discounts on the claim form. This policy is in
accordance with the N.J. State Board regulations,
N.J.A.C. 13:30-8.10(c), which reads in part:
"A licensee who renders
dental services or procedures to a patient enrolled in
any dental plan with co-payment features and who intends
to waive any part of the co-payment or all of the
co-payment by the patient shall, when submitting any
claim or bill to the third-party payor, conspicuously
disclose on the face of the claim or bill in a legible
manner, or in the electronic claim submission, that the
co-payment, or a portion of co-payment, shall not be
billed to, or collected from, the patient."
Knowingly making a false statement
on an insurance claim is fraud. The New Jersey Insurance
Fraud Prevention Act (IFPA) N.J.S.A. 17:33A-1 and the
New Jersey Administrative Code (N.J.A.C. 11:16-6)
require insurance carriers to detect, investigate and
report fraud.
Every subscriber and dentist
should strive to assure the accuracy of the services and
fees submitted. Although you might not see the claim
form before your dentist submits it, Delta Dental always
mails you an Explanation of Benefits statement, which
details what services were performed and how much was
paid to your dentist. You should review these statements
for accuracy.
As a dental benefits provider,
Delta Dental is responsible for reviewing and paying
your claims. It is also our responsibility to provide
assurances to our employer groups that we deliver
benefits in the most efficient and cost-effective
manner. Toward that goal, we verify the accuracy of
claims on an ongoing basis to keep group premiums
affordable. Fighting fraud enables Delta Dental to help
companies manage their benefit costs while providing
excellent dental benefits to subscribers like you.
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