How To Respond When Insurance Makes A Mistake And Patients Blame You

Narrator: You are listening to Insurance Untangled podcast, where we explore the various challenges faced by dental practices due to their reliance on insurance. In this podcast, we dive deep into the issues surrounding dental insurance dependence and offer practical solutions and strategies for reducing your reliance on insurance. Join us as we interview industry experts, share success stories, and provide valuable insights to help you take control of your practice’s financial future.

Ben Tuinei: Welcome to another exciting episode of the Insurance Untangled podcast. My name is Ben Tuinei, and I’m one of the co-hosts on this podcast. And as you all know, we’ve developed this podcast for you to help you untangle yourselves from the mess of insurance that continues to bother us, distract us, and take us away from, well, take us away from the important part of our lives, which is helping patients get healthier. So, thank you for joining us today. We have a fun and amazing episode lined up today. We have Tessina back with us today.

Ben Tuinei: Tessina, how are you?

Tessina: Hey, I’m good. How are you?

Ben Tuinei: Good. Good. By popular demand, people are like, where’s Tessina? Where’s Tessina? Where is Tessa? So, we just took a little bit of a break to allow other guests to come and chime in on their topics, but Tessina is a permanent fixture of this podcast. And so, today we want to sort of talk about an issue, Tessina, that you and I have been talking about for a long time, and the topic is what to do when insurance makes a mistake and patients then blame you for what insurance did wrong.

Ben Tuinei: Yes. So this is the reason why insurance companies were so happy that our medical colleagues started to accept assignment of benefit, which means the doctors then took their benefit responsibility away from the patient, and the patient then has no responsibility to file a claim. It’s now on the doctor’s office. That was a big mistake. It still is a big mistake today, and I get it, that we do that to make it a convenience for the patient. We do that because the insurance companies have convinced us that that’s how you get patients to accept treatment.

But the problem is, is that you’re basically managing a huge component of insurance that should be on their payroll, but it’s on yours. So how do you deal with that? How do you deal with a situation when insurance makes mistakes? And we’ve trained our people to be so insurance-driven—our patients to be insurance-driven—which to me is mistake number one.

Yeah. And now that’s a—yeah. Yeah. And now patients are giving us a hard time. It’s like, we don’t process your insurance. Like, seriously. And you just want to, like, you want to throw—you want to read the riot act to these patients or the insurance, but you can’t. Right? It’s like, you do that and the patients will smear you online. So it’s a delicate situation, right, Tessina?

Tessina Bullock: Yes, definitely. It is a very delicate situation, but I agree. The number one thing is making sure that the patients are actually educated and not insurance driven. Anytime a patient tries to go insurance driven or insurance minded, it’s our job to redirect the conversation or redirect their focus so that they properly understand what is what, what the task is at hand. Right?

So if we’re talking about treatment that they need and they say, does my insurance cover that? And, again, right? We’re redirecting the focus of like, well, we’ll definitely look at your insurance coverage, but here’s what your body needs. Here’s what—yeah. It doesn’t, regardless of insurance, that doesn’t really change what you need. And there’s all these opportunities we have available.

And I know a lot of managers have been in the same situation that I’ve been in where the patient is up for open enrollment or switching companies or anything, and they want to ask us our opinion on what insurance companies are good to work with.

Tessina Bullock: And instead of just throwing out a list, that’s another education opportunity where we can go through just kind of like a brief explanation or reminder again that insurance companies are more like a discount for dental services. It’s not really like a medical plan or, you know, a home insurance policy or something like that. It’s just a discount of dental services. And we take a look at what their needs are for their health and their family. And I always evaluate like, are their needs enough needs to support needing an insurance discount?

If they don’t have very many needs and their family’s really regular, I don’t always recommend that they get any dental insurance plan. They may not be in need of that dental discount because their family is really regular and we can just take care of them with our in-office discount plan.

Tessina Bullock: But, so step one—sorry, long explanation. Step one is educating the patients, making sure that they are not insurance driven and insurance minded, but that they are healthcare driven and healthcare minded, and that they understand the tactics and the gains at the length that the insurance company goes to. And then I also educate them on the efforts we make on their behalf to battle that for them. And they’re always so grateful at the lengths that we go to, to protect them and protect the benefits that they have available to them.

In such that when we have a mistake on the insurance side and they do something like that—for me, because I’ve already been educating my patients—it’s a really easy conversation to be like, here we go. This is one of their mistakes that they’re known for. This is a new trend that we’re seeing with this specific company, and here are some options for you, and here’s what I have done to also protect you. So sometimes it’s just something on my end I can do, and sometimes it’s both of us have to get involved in order to resolve that. And they are prepared for that. They know about it, they understand it because we’ve been educating the whole time.

Ben Tuinei: Yeah. No, I love that. I think that’s important for dental pra—well, doctors—to understand, practice owners to understand, because when you really think about it, why do patients feel so insurance driven? Well, sadly, the answer is that we’ve taught patients to be that way. You know, and the good news is that you can reverse that by talking more about the quality nature of what patients need, exactly what Tessina mentioned—like educating patients.

If you want to educate, check out our blog on our website, veritasdentalresources.com. You’ll find a lot of great articles about the history of dental insurance and the fact that dental insurance was started by our dental associations—at least a big part of dental insurance was—and naturally, that was hijacked by business people, right? That were just interested in money and a good employment.

Ben Tuinei: Delta Dental being nonprofit—who runs Delta? Well, the brokers do. It’s the people that sell insurance. It’s not the people that do clinical dentistry. So naturally, you have all these people that are trying to grab some money off of the treatment that you are doing.

And so my philosophy is, you gotta put an end to that. We gotta educate everybody about how insurance works. Dental insurance was started by MetLife and then subsequently run by the dental associations that created Delta Dental. And their annual maximums in the 1950s were $1,000. Yeah. Yeah. And then it bumped up to $1,500 in the 1970s, and never changed since then.

You know, so I think your points, Tessina, are pretty spot on. So there’s a current situation, Tessina, where doctors are being dropped by plans—well, certain plans. I don’t want to mention them. I’m tired of getting lawsuits from them.

Ben Tuinei: Since we’re using our freedom of the press rights to share what we find, you know, and they still sue us. It’s like, seriously, you’re trying to restrict free speech. That’s what’s going on with insurance carriers. That’s really frustrating for me.

Yeah, Tessina can relate to this. Earlier this year, we dealt with a particular insurance company that was trying to silence free speech. That’s just wrong on every level because we’re just trying to educate the doctors on what’s going on. And insurance companies continue to sue us.

So we will get back to mentioning their names—we’re just trying to recover from the most recent horror story of defending ourselves and defending our livelihoods from greedy insurance people. You know, so there’s a particular insurance company right now that is dropping every dentist that’s part of an umbrella network, or that’s in-network through that particular dental plan via an umbrella network.

This just so happens to be an insurance company whose out-of-network benefits are among the best in the industry. But what do you do when stuff like this happens? Like, you don’t get notified, the patient doesn’t get notified, and then all of a sudden the EOBs are coming back out-of-network. And sometimes insurance pays more, sometimes they pay less. That would then place a balance for the patient to pay for that treatment.

What are some of your thoughts on that, Tessina, on how that particular situation can be addressed?

Tessina Bullock: Yeah, exactly. This has been a wild event that offices have had to go through. And again, some are somewhat better prepared for how to handle these situations, and others are completely blindsided.

I’ll tell you the wrong initial thought process is, "Oh no, how do I get in-network? How do I get back in-network?" That’s the wrong thought process. We don’t want that thought process because that’s going back to being insurance driven.

So let’s say, okay, how do we manage the situation? This company dropped us. We’re actually fine with being out-of-network if this insurance company does not support quality dentistry—because that’s what we provide: quality dentistry.

How do we help our patients? How do we take care of them? Because that’s our focus. And that’s what we need to relate to our patients as well, is that this insurance company has put us all in this situation and in this predicament, outside of our control. There are things we can do, like make sure that our patients are taken care of.

Tessina Bullock: Honor any quotes that were previously given to them for the time being while you get a handle on what the plan is moving forward. Also, making sure that they know their rights—that they have been abandoned by this insurance company—and therefore scrambling to find out if they have to switch providers or not.

The letters are making it appear that they have to hurry and find a new provider. Some of these patients are scheduled the next day after they receive this letter, and they’re abandoning their appointments or trying to figure out what to do in such short notice. It’s really unfair and cruel.

The laws are not very clear. We have our patient abandonment laws, but that protects patients from offices abandoning them, not from insurance companies. But I promise, the louder your voices are, the more your voices are, the more that these insurance commissioners and governors will take this problem seriously and will make it a matter—they’re just not aware of the situation.

Tessina Bullock: So our job is to make them aware. I would make sure—and if we complain as the providers, which I do recommend we do—but when we do that, the insurance companies try to make it about us and our battle with the insurance company.

But when the patient complains and reaches out to an insurance commissioner or a state legislator about these types of concerns and how they were negatively affected by it, that’s a different conversation. Because now, all of a sudden, it’s real people. Not that we as dentists aren’t real people.

Tessina Bullock: I’m just—nobody cares, right? When they’re like, "Oh, the dental office had a problem with the networking issue," they don’t care as much as when somebody’s like, "I wasn’t able to get my tooth fixed that day. I wasn’t able to go to my appointment," or, "I had to find a different doctor, and that different doctor messed up my work, and I preferred my old doctor."

All those problems that were generated unnecessarily by an insurance company—randomly. And they’re saying it’s random, but it’s not. It is very selective. They’re purposely targeting certain offices to drop. But making sure that those patients know how to file complaints with an insurance commissioner, and also that they know how to reach out to their state legislator to make them aware of the problem as well. Bills and legislation can go into place to correct this moving forward.

Ben Tuinei: Yeah, I love that. So a lot of that is definitely really great solutions. And I think if more dental practices get on the horn with the insurance commissioners to report bad behavior—and I get it, like a lot of people are raising their eyebrows, "My insurance commissioner sucks." Yeah, ours did too, but not anymore.

You sort of train the insurance commissioners in certain states to start thinking about these things because this is all what the insurance commission is designed to do, which is protect the consumers, right? Protect the public.

And unfortunately, you know, you have this issue with this UnitedHealthcare CEO that got assassinated in December 2024. The public is aware of this culture of denial that’s going on, right? So it is in our best interest as patients and as clinical providers to make more awareness on these issues so that it puts pressure on the insurance carriers to do better, you know?

So, yeah. So last question I have for you, Tessina, is: when this happens, and let’s say we get dropped by an insurance company, we didn’t get notified, and the patient most certainly didn’t get notified either—what do you recommend in that scenario? Do we stay in-network? Do we negotiate to try to go back in-network? What say you?

Tessina Bullock: I would recommend staying out of network and acting as if you’re pleasantly happy about it. If we all rush—this is kind of what I was saying before—if we all rush to be back in network, the insurance companies feel like they’ve got the power chip on their end, right? The ball’s in their court, and they can say, "Well, this is the fee schedule we’re gonna give you, and you have to take it," and it’s not gonna be a good reimbursement rate.

And you’re in the mindset of, "But I need to be in network." So get out of that mindset and say, "We’re okay to be out of network, and we’re happy with it." And we’ll make sure all of our patients know that you are the reason we’re out of network. Not us. We didn’t make this choice. But we’ll stand by it because we’re not gonna be bullied by insurance companies to be forced to be in-network with restrictive services that we’re allowed to provide or restrictive reimbursement rates.

Ben Tuinei: Love it. I agree with you. Stay out of network with these plans and embarrass them in front of your patients. Let them—exactly what Tessina had mentioned—know it wasn’t your choice to go out of network. The insurance company chose that. Oh, and by the way, they chose to not notify you as a patient, and they chose not to notify us as the doctor. You know? So it’s their issue.

And I think if we do more of that, the insurance industry is losing this game that we’ve been—well, I don’t think the doctors have ever intentionally tried to get into a game with these insurance companies…

Tessina Bullock: Created it, but—

Ben Tuinei: We’ve been—yeah. They created the game, and we’ve been playing it since the nineties. Yeah. And so enough is enough. You know, it requires the clinical community to be bold, to be willing to take risks, and be willing to fight. You know? Yeah. Without a good fight… if you wanna let the bullies take over, then have at it. But I’m not. You know, Tessa and I are not gonna do that.

Tessina Bullock: Yeah. And to add to that, Ben, I mean, I would recommend that the patients drop that carrier as well—that they show that they don’t support that treatment either. And that they instead can use the in-office discount plan of that office or choose a different carrier. They should take a stand as well.

Ben Tuinei: Yes. Yes. And it’s interesting that when the patients and the employers complain, there’s almost immediate change on the part of the insurance, right? But for that one incident that you’re complaining about—not the global problem of dental insurance in general.

So you’re right. I think if you switch to an in-house membership plan—if you need recommendations for that, let us know—but that’s a great solution as well to get patients to take business away from the insurance, which is what it really boils down to. Right? If they don’t—if they can’t survive, or they feel like they really need you and you’re not willing to cooperate—then they’ll just go away. You know? Yeah. So, yeah.

Tessina Bullock: Sorry, one more thing I wanted to make sure I added. We’re taking care of those patients. So having a strategy for when you’re out of network—of what discounts or sliding fee schedules you can offer to your patients who qualify for those discounts. You’re not in network; you’re out of network. So you can adjust those fees.

You need to charge your UCR fee, but you can offer discounts to patients at your discretion. So come up with a plan for that—of what discount you’d like to offer them to continue to come to your office—and let them know that you are taking care of them, even though the insurance company is not. And they can still use that plan if they choose to, although we recommend they drop it to show that they’re not happy with how they were treated. But you’ll take care of them in the meantime.

Ben Tuinei: Yep. Lots of options for our patients, lots of options for you as the doctors, and we thank you for joining us today. And thanks, Tessina, for all your wonderful insights. Yeah. Let’s not let these insurance companies win when they should take responsibility for their mistakes. So that’s what the theme is.

Now, I just want to put a plug for Tessina. Tessina is an expert at all things insurance. If you need coaching on front office insurance-related tasks, or just front office in general, as well as negotiations with insurance credentialing, those are things that Tess and the team can take care of.

Visit verusdental.com to request a consultation with Tessa directly, and of course, she’ll be happy to chat with you, answer questions, and of course, give you any direct feedback. You don’t have to pay for good feedback—we’re willing to give that to you no matter what.

Closing Thoughts

Ben Tuinei: So check out Tessina on her website, verusdental.com, for that information. Just want to take a minute to thank you, Tessina. Thank our listeners—another great episode. Thank you. Thank you so much.

And check out insuranceuntangled.com for future webinars, including our upcoming episodes that we publish weekly. And if there’s any of you that want to share any amazing content on our platform or on our podcast platform, just reach out to us at insuranceuntangled.com. We’d be totally happy to entertain your thoughts and bring you on our program.

Until we meet next time, folks, thank you again for joining us today, and we wish all of you the very best of success. Take care now.