Both, depending on the product. The question behind delta dental coverage bills pay after or copay is which of two payment models the patient's plan uses. A Delta Dental PPO or Premier plan is fee for service: you submit a claim, the plan pays a percentage of a contracted allowable, and the patient's real share is settled on the explanation of benefits after the visit. A DeltaCare USA plan is a dental HMO: the patient owes a fixed copay from a published schedule, due at the visit.
Same familiar name on the card, two different jobs for the front desk. Getting it backwards costs money in one direction and creates refunds in the other.
The card says Delta Dental, which settles nothing
Delta Dental is a national association of independent member companies, each licensed in its own states, each with its own fee schedules and processing policies. Sold through that system are several product families, and the two that matter for this question behave nothing alike. On top of that, the employer group that buys the coverage picks the provisions inside it, so two patients holding cards with identical artwork can carry different coinsurance percentages, different deductibles and different maximums.
That means no article, including this one, can tell you what a particular patient owes. What it can tell you is which question to ask, and the question is the product name, not the brand.
Read it off the eligibility record for that patient and that date of service:
- The product and network. PPO, Premier, or DeltaCare USA. Some member companies also market other network tiers, and a patient can be in network for one and out for another.
- The group number. The group is the unit that owns the provisions. Two employees of different companies under the same member company are two different plans.
- Whether a patient charge schedule applies. If the answer is yes, you are in copay territory. If the answer is coinsurance percentages by category, you are in fee for service territory.
- The plan year. Copay schedules and fee schedules both carry effective dates, and treating from last year's version is one of the quieter ways to misquote a patient.
One extra check belongs to the dental HMO side only, and skipping it is not recoverable by any claim. A copay plan pays your office for a patient assigned to your facility, so two things must both be true on the date of service: your office holds the facility agreement, and that patient is assigned to your facility number. Assignment changes normally take effect the first of a month, so a patient who enrolled last week may not be yours until the first. Confirm the effective date with the member company before you book.
Copay, coinsurance, deductible: three words, three amounts
Staff use these interchangeably at the desk and they are not interchangeable at all. Here is what each one actually does to the number the patient pays.
| Term | What it is | When the amount is known | What moves it |
|---|---|---|---|
| Copay | A fixed dollar amount tied to a specific procedure code | Before treatment, from a published schedule | The plan year, the schedule version, specialty referral |
| Coinsurance | A percentage of the plan's allowable for that code | Only when the claim adjudicates | Fee schedule, category percentage, deductible, remaining maximum |
| Deductible | An annual dollar amount applied before coinsurance pays | Partly known, if usage elsewhere is reported | Care at another office, family versus individual accumulators |
| Annual maximum | The ceiling on what the plan pays per benefit year | Partly known, if usage elsewhere is reported | Every claim paid anywhere that year |
| Write off | Your fee minus the contracted allowable | When the claim adjudicates | Your fee schedule, the plan's allowable |
Two of those five belong to the practice and never to the patient. The write off is yours by contract. The difference between your fee and the allowable is not a patient balance, and billing it to a patient under a participating agreement is balance billing. Deductibles cause more estimate misses than any other single field, and our guide to the dental insurance deductible explained walks through the accumulator problems that create them.
Run the arithmetic before you quote a number
Take one crown, D2740, crown, porcelain or ceramic substrate, with an office fee of 1,400 dollars. The figures below are illustrative, chosen to show the mechanics rather than to predict any real plan.
Under a fee for service plan with a 900 dollar contracted allowable, major services at 50 percent, a 50 dollar deductible not yet met, and enough annual maximum left to cover the claim:
| Line | Amount |
|---|---|
| Office fee | 1,400 |
| Contracted allowable | 900 |
| Contractual write off, 1,400 minus 900 | 500 |
| Deductible applied | 50 |
| Plan pays, 50 percent of 850 | 425 |
| Patient owes, 900 minus 425 | 475 |
Under a dental HMO plan whose patient charge schedule lists that code at 400 dollars, the whole table collapses into one line. The patient owes 400 dollars at the visit. There is no allowable to reconcile, no write off line, and no balance that arrives three weeks later, because the plan's contribution to your office reaches you through capitation and any supplemental payments the contract lists rather than through that claim.
Notice which model is harder. The copay plan is a lookup. The fee for service plan is a calculation with four inputs, two of which, the deductible and the remaining maximum, depend on what happened at offices you cannot see. That is the whole reason one bills after and the other does not. Our step by step formula for estimating dental insurance coverage sets out the order of operations, which matters more than it looks: applying the deductible after the percentage instead of before changes the patient's number on every major case.
Collecting at the visit when the plan settles after
Under a copay plan there is no decision to make. The amount is printed, it is due at the time of service, and collecting it later is a choice to chase money you were handed a schedule for.
Under a coinsurance plan, anything you collect at the visit is an estimate, and your policy has to say what happens when the estimate is wrong in either direction. Practices generally pick one of three:
- Collect the full estimated patient share at the visit. Highest collection rate, highest refund volume. Works when your estimates are tight and your refund process is quick.
- Collect a fixed deposit on major treatment and bill the remainder. Lower refund volume, more statements.
- Bill everything after the explanation of benefits. Lowest friction at the chair, worst aging, and the point where a routine crown becomes a 90 day balance.
Whichever you choose, the sentence at the chair is the part that actually determines whether it works. Tell the patient the number is an estimate, tell them what the plan has not yet confirmed, and tell them how a difference will be handled in both directions. A patient who was told about a possible 60 dollar balance pays it. The same patient billed 60 dollars without warning calls to argue. Our guide to collecting dental patient copays upfront covers the scripts and the exceptions.
Hygiene visits are where the two models look most alike and behave least alike. A recall appointment billing D0120, D1110 and D0274 may cost a copay plan patient a small listed amount per code, while the same appointment on a fee for service plan whose group covers diagnostic and preventive at 100 percent with the deductible waived costs nothing at all, and on a group that covers preventive at 80 percent with the deductible applied costs real money. Same three codes, same office, three different answers, all decided by the group rather than the carrier. That is why a verified schedule of benefits beats a memory of the last patient with the same card.
Two constraints sit on top of that choice. A participating dentist may bill the patient the deductible, the coinsurance or copay, noncovered services and amounts above the annual maximum, and not the contractual difference. And an overcollection creates a credit balance that has to be refunded, on a timetable set by your provider agreement and by state law. As of this writing those refund windows vary by state, so confirm yours with your state insurance department rather than with a rule someone remembers from a previous job.
When the explanation of benefits disagrees with you
On a fee for service plan the remittance is the settlement, and it is also the only place a quiet loss shows up. Work it line by line against what you estimated:
- Allowed amount below your contracted rate. Either your stored fee schedule is stale or the claim was priced on a different network tier. Both are appealable, and both repeat until someone fixes the stored rate.
- A cheaper procedure paid instead. An alternate benefit provision pays the least expensive acceptable treatment and leaves the patient the difference, which arrives as a lower allowed amount rather than as a denial.
- Deductible applied when you thought it was met. Family accumulators and mid year plan changes both do this.
- Maximum exhausted. Another office got there first, which is why the remaining maximum you verified in January is not the remaining maximum in October.
- Coordination with a second plan. When a patient has two plans, the order of payment decides the arithmetic, and our guide to coordination of benefits in dental insurance covers how the secondary is supposed to calculate its share.
On a copay plan the same check is shorter but still worth doing. If the patient paid something other than the schedule amount for a listed code, the wrong schedule or the wrong plan year was used, and the correction belongs on your side of the desk.
The cases where neither model applies cleanly
Three situations break the copay versus coinsurance frame entirely.
Services the schedule does not list. Under a copay plan, a procedure absent from the patient charge schedule is not free and is not automatically your office fee either. The contract says which it is. Verify before treatment, because this is the most common source of a surprise balance on a plan the patient believes has no balances.
Specialty referrals. Care referred out under a dental HMO typically runs on a separate copay schedule at the specialist, which means the estimate you give for the surgical portion of a case may not be yours to give.
Cases where medical is the primary payer. Trauma, pathology, certain surgical extractions and sleep apnea appliances often belong on a medical claim first, where the patient's share follows medical deductibles and coinsurance and has nothing to do with the dental copay schedule. Start with how to bill medical insurance for dental procedures, and for accident cases specifically, how to bill medical insurance for dental trauma and accidents.
Make it one page at the front desk
The decision a treatment coordinator needs is small enough to fit on a card next to the monitor. Product name from the eligibility record. If a patient charge schedule applies, collect the listed amount today. If coinsurance applies, price it from the verified allowable, the deductible status and the remaining maximum, say the word estimate out loud, and collect according to one written policy rather than one person's mood.
Curo verifies the full benefit set for each scheduled patient, including the product, the network and the patient's share, so the number quoted at the chair is priced from the same allowable the remittance will use, and the balances that remain after the claim can be worked through balance collection instead of aging quietly.
The trap in this question is assuming the answer is a property of the carrier. It is a property of the plan design, and plan design changes every January for a portion of your schedule. The office that reverifies products at the plan year boundary spends the rest of the year quoting numbers that hold.