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Three Council Bluffs dentists allege a private nonprofit tapped to run a state dental insurance program for low-income Iowans is rejecting more claims than other insurers typically would, forcing them to provide substandard care.
Robert Colwell, Kate May and Richard Duvall have also filed a complaint with the Federal Trade Commission and the U.S. Justice Department, alleging they were illegally penalized as whistle-blowers for reporting problems with the program run by Delta Dental of Iowa.
The three, who also practice in nearby Bellevue, Neb., petitioned the Iowa Department of Human Services to have an administrative law judge interpret Delta Dental’s contract. That judgment, expected in about a month, will help decide whether Delta Dental acted within the law when it terminated the contract with the dentists in January with no cause.
Colwell says he and his associates withdrew a lawsuit this year in Polk County because it would have proven too expensive. Instead, he says, they are pursuing their case administratively through DHS to better protect the almost 136,000 members who have enrolled in the Dental Wellness Plan.
“The state should be stepping in on this, and it is not,” he said. “Enrollees are not getting the care they need.”
Jill Hamilton, a spokeswoman for Delta Dental, said the Johnston-based company denies all the dentists’ allegations.
She claimed neither Colwell nor any of his patients have appealed claims through Delta Dental’s or the state’s appeal process.
But Colwell says he and his colleagues have filed hundreds of online appeals over rejected claims. The problem, he says, is that unlike other insurers, Delta Dental requires that patients participate in appeals to proceed and many won't.
“We can’t even get some of our patients to show up for appointments,” he said.
Colwell says the company also requires many more narratives of cases for claims to be paid, placing a huge burden on dentists.
"They are trying to dictate to doctors how to practice dentistry, or they won't be paid," he said.
Iowa Medicaid contracted with Delta Dental of Iowa in May 2014 to provide comprehensive dental benefits for low-income, uninsured adults. The benefits are supposed to be equivalent to Medicaid’s current dental program, but members become eligible for enhanced benefits with regular follow-up exams.
Colwell contends that since Delta Dental began managing the program it has routinely rejected cases needing immediate attention.
“We have patients who have infections, deep decay or need a root canal. But under the contract with Iowa Medicaid, Delta Dental isn’t allowing these procedures,” Colwell said by way of an example.
Colwell alleged that in some cases decisions to deny claims are being made by dental hygienists, which is illegal.
But Hamilton said such decisions are made by licensed dentists with years of experience and the claims are denied because they do not meet clinical criteria.
I filed an open records request with DHS to see if any other dentists in Iowa have voiced similar complaints with Delta Dental.
Amy Lorentzen McCoy, a spokesperson for DHS in Iowa, said none have. “We are hearing the program is going really well,” she said.
Lorentzen McCoy declined to comment on the dentists’ allegations because of the pending petition with DHS.
According to Delta Dental’s last publicly filed tax return in 2013, the company had year-end assets of almost $60 million. At that time, the company’s president and CEO Jeff Russell made $256,633. That was before the company won the contract to administer the statewide program.
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