Fighting the Culture of Insurance Claim Denials in Dentistry

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Narrator: You are now listening to another episode of the Insurance Untangled podcast, where we explore the various challenges faced by dental practices due to their reliance on insurance. Join us in this podcast as we dive deep into the issues surrounding dental insurance dependence and offer practical solutions and strategies 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, this is a podcast that’s for you to help you untangle yourselves from the, I guess, complex and confusing nature, and the often unfair nature of dealing with insurance. So today we have our co-host Tessina with us. Rejoin us once again. Tessina, how are you?

Tessina Bullock: I’m good, thanks.

Ben Tuinei: Good, good. Always great chatting with you and picking your brain. And so we planned a really quick episode just to talk about this whole culture of denials that are going on in dentistry now. Some real quick numbers to kind of go through. What we’re really dealing with is that, you know, there are about 60 to 65 billion dollars worth of claims that go to insurance companies every year. And out of that money, closer to 12 billion of that gets denied. And out of that 12 billion, only 1 billion gets overturned. You know, something along those lines. You know, the numbers are not exactly accurate with what I mentioned, but they’re pretty close. And so when you really think about it, there’s over 10 billion dollars of money that should go to dental practices that subsequently get denied. And in large part, to me, it’s a function of appeal, proper appeal, understanding the regulations, and just being creative in your advocacy work against these insurance companies. So, Tessina, these days we see all kinds of issues in terms of the denials, but what are some procedures that you are seeing in terms of a pattern that kind of scream out? Like what category of treatment is typically denied?

Tessina Bullock: Yeah. Right now, I think everybody knows—we’ve mentioned it in a couple of recent events as well—but the SRPs are denying like crazy all over the place, across all the different insurance companies, all the different employers. This is a really big one that needs to be appealed, needs to be advocated. We have insurance companies saying that they don’t see the bone loss, even though it’s being measured by AI or even just the measuring tools within the software itself. So they circle it, they highlight it, they measure it, and then the insurance company just says, "I don’t see the bone loss," like there’s no bone loss.

So the problem is—and I always advocate to send this to the insurance commissioner—the insurance commissioner will say, "We’re not dental consultants. We cannot say whether or not there is or is not bone loss."

Tessina Bullock: And they’re saying they had a dentist review that. So two things here. Ask for that peer-to-peer review with the consulting dentist. Most insurance companies are not allowing that anymore, and even though they’re supposed to, they have wording and verbiage to get them out of that. But still request it, because you want to show proof that you were denied the opportunity to discuss with the reviewing dentist why they’re not seeing the clear bone loss that you have circled, highlighted, and measured.

So we need to point out that that’s being denied or refused—to speak with that reviewing dentist. Also—what… I lost my train of thought now when I got off of that—oh, when we’re pointing out to the insurance commissioner, we’re not asking them to make a diagnosis. What we need to point out to them is that we have provided the clear documentation that have followed the guidelines and the coverage of the insurance plan and the patient’s plan.

Tessina Bullock: ‘Cause the contract is between the patient and the insurance company. So you have followed those guidelines. You have given the proof, and they are blatantly ignoring it in order to deny the claim. And ask them also to see the trend—ask them how many of these denials they’ve been seeing, or how many of these complaints they’re getting for these SRP denials.

So some of that work is on us. If we’re not submitting it to the insurance commissioner, they can’t see that trend. So we have to be showing that trend, and they’re like, "Okay, we have a million denied SRPs all saying we gave them bone loss. They’re saying they don’t see it." They see a trend. Instead of saying, "We can’t diagnose this," I’m not asking you to diagnose. I’m asking you to look at the trend, look at the facts. They are denying these wrongfully. Right?

Ben Tuinei: Right, right. Yeah. Yeah. And you know what’s interesting, Tessina, you mentioned something about how these insurance companies are refusing to allow you to talk to a dental consultant, which is—they’re licensed dentists that kind of help scrub and check for fraud, you know? And the interesting thing is because they don’t want their names to be used against them, you know?

And right now I advise doctors to request HIPAA disclosure on who reviewed the claim and who denied it—what are their credentials, right? And you could use that to contact the dental board and say, "Look, these folks are diagnosing dentistry, and if they have a license, it’s still considered diagnosing dentistry without a license." ‘Cause a lot of times, you know, licenses are out of state, but still, the dental board has specific protocols on how to issue a diagnosis—what do you need to do to do that under a license, you know?

And so the insurance companies are aware of that, and they’re aware of these techniques. And so I would use the HIPAA disclosure requests. If you are having trouble, just contact them and say, "I want to talk to the privacy officer, the HIPAA-compliant officer," and then make a request on who had access to the patient’s record. Because HIPAA requires you to disclose that if it’s requested.

Tessina Bullock: Yeah. And I have seen where they will list the consulting or reviewing doctor’s credentials, but that you’re not allowed to speak with them. And I’ve done this for a long, long time, and when we used to be able to speak to them, it was very clear that they would tell me, "Yeah, I see it. Yeah, I agree with your diagnosis." However, the insurance company is still insisting that I process it—or request it—for denial. So I would use that against the insurance company for my complaint to the insurance commissioner, saying I have the word of the reviewing dentist saying he or she agrees with the diagnosis.

But there’s this fine line that says like, oh, if they didn’t dot the I, then you have to still process it even if you agree with the prognosis, right? So they are insisting on denials not based on care, but based on some arbitrary filing process that the office usually is not aware of. But now they’ve even restricted that access. Now I’m having a hard time even getting to those reviewing doctors. I’m still requesting it. Like I said, I still am giving that proof to the insurance commissioner, and that is super helpful.

Ben Tuinei: Yeah. And it’s one of those things where you have to ask—if the insurance is not gonna be upfront about putting you in touch with the people that they say that you could talk to to appeal something—what do they have to hide?

Tessina Bullock: It’s pretty obvious.

Ben Tuinei: What are they afraid—

Tessina Bullock: Have a lot to hide. Yeah.

Ben Tuinei: So I wanna point that out because we’re winning this battle. We are winning it. The dental industry—the clinical industry, administrators, insurance coordinators, all of us—we’re all winning this battle against insurance. And so, you know, I would say to those of you that haven’t tried these things to give ’em a try.

What other—so what other category of treatment, Tessina, for the listeners outside of perio scaling and root planing… Oh, by the way, before we get into that question—yeah—with all this advocacy work that’s going on, Tessina, your work, the work of professionals around the industry, the American Dental Association has had so much fuel to fight these insurance companies as of late. And the most recent success is that the ADA was successfully able to get Florida Combined Life, which is the Blue Cross—Blue Dental, Blue Cross Blue Shield in Florida—to eliminate their policy on scaling and root planing.

Where in the past, it would only allow you to do two in a single day of service, when there’s all kinds of clinical evidence that—look, there’s bacteria everywhere else in the mouth, you know what I mean?

Tessina Bullock: Yeah.

Ben Tuinei: These people—your policy is preventing people from getting healthier, you know?

Tessina Bullock: Yeah.

Ben Tuinei: And so now they’ve lifted that policy. And you know what? So now they’re allowing all four quads to be performed and billed on the same day. And you’re gonna start to see that in the sense that these ridiculous policies that go against the science of dentistry—that the science is winning. And so, with that said—ho—but that’s not to say that your problems on getting paid for scaling and root planing is gonna go away. It’s still gonna happen.

Tessina Bullock: Right. But we’re seeing changes. We’re seeing progress.

Ben Tuinei: Right.

Tessina Bullock: Yeah. Positive movement. Yeah, I agree. And the ADA has come up and said that on certain issues that they do want to be notified. So not just complaining to your insurance commissioner, but also complaining to the ADA.

One example specifically—and this kind of goes into some other denial we’re seeing, but more than a denial, more of a bundling—4212, which is the gingivectomy for restorative access. So if you bill a 4212 and a filling the same day, the insurance companies will bundle the two together and say that you can’t bill a 4212 because it’s considered part of the filling procedure.

That is not allowed. The ADA itself does not approve that. And they have said if you come across the situation, you need to contact us and report that insurance company. The ADA will go after them, ’cause they are not supposed to be recoding or changing the definition of a code—that’s not allowed.

Ben Tuinei: That’s right. Right. That’s—that’s right.

Tessina Bullock: So, yeah. Yeah. So that’s super fun. So keep that in your back pocket too. I’m always like, go to the insurance commissioner. But more than that, you can go to the ADA as well. There’s—they have some limits as to what they can do—but they can do a lot. So if we report these issues, we will continue to see this forward progress.

So another one that gets denial a lot—buildups. We talk about this all the time, but it is still a very common denial and a very common question we’re getting asked about. So again, we’ll just address it. If your buildups are getting denied and saying—again, bundling—saying it’s included, it’s part of that service of the crown, it’s not. You need to appeal that, point that out to them.

They do like to know that 50% of tooth structure was lost. So I’ll tell you, the insurance company is saying that the reason they’re bundling it is because offices don’t know what qualifies as a buildup or not, right? So they’re saying, "Well, you always put some material in there before you do a crown," and offices are miscoding. So if you show proof that you have not miscoded—that tooth has lost more than 50% of tooth structure and it required the buildup for crown retention—they have to, by ADA law, they have to pay it as a separate procedure.

Ben Tuinei: Yeah. Yeah. And by way of ADA law—just to kind of explain that a little bit further on what Tessina mentioned there—is there’s an actual agreement between the insurance companies and the American Dental Association in which the insurance companies agree to follow the codes as they are written. And the insurance companies have no authority over the codes, but they change the codes all the time to deny claims. And we know how that shakes down, you know?

And so, you know, that’s really great advice. I really appreciate you mentioning that on those buildups. You know, it’s—it’s just really interesting to me that these insurance companies engage in these activities, but they don’t—they don’t do a good job explaining why. And this is not—I’m gonna say something that’s not in defense of insurance—but it’s another reason why you see this crazy high denial rate on buildups and things like perio, which are the two categories of treatment that tend to get abused a lot from an overbilling perspective.

Ben Tuinei: A lot of practices submit for buildups when a buildup was not even performed. I mean, something not even remotely close to a buildup was performed. And you have a culture where a lot of times people just send codes to insurance—whether they’ve done them or not—to see if they’ll stick and they’ll get paid for it. And there’s temptation to do that in a down economy.

My advice is—don’t do that. Because the minute your reputation and your record is tainted—that you committed fraud—it’s so hard to reverse, to recover from something like that. But that is another reason as to why you’re seeing these denials, is that unfortunately, the bad apples are doing the bad appling that’s making the rest of us that are honest apple eaters have a hard time, you know?

Tessina Bullock: I agree a hundred percent. And I mean, in a down economy, but just those reimbursement rates, right? So the doctors are frustrated with that, and that creates an incentive to try to add on as many codes as we can to get that claim dollar amount up, that reimbursement amount up.

That is not the way to do it. We never advocate for that. If you are unhappy with your reimbursement rates, look at dropping the plan, going out of network, negotiating those rates—there are other options. You never, ever, ever want to just tack on whatever you can to get that reimbursement rate up.

Ben Tuinei: Yeah. Because what does that do in terms of your future history to advocate? Is that if you have a record of overbilling or committing fraud from any perspective, you’ve lost all future leverage to appeal—effectively. You’ve lost a lot—maybe not all—but you’ve lost a lot of leverage.

Tessina Bullock: Yeah.

Ben Tuinei: So definitely. So that’s good advice. And so this is great, Tess. And I understand that you coach on these things.

So to our listeners, the culture of claim denials is increasing, and it’s not going to let up for a while. Insurance companies have to find ways to make money and save money with what they’re— you know, we’re all dealing with inflationary economic issues. And sadly, you have industries that take advantage of others, and that’s what goes on in a dynamic like this, where you are seeing insurance companies tighten their belt. And subsequently, that’s causing doctors to pay more in payroll to get their claims paid.

Tessina has some amazing solutions that prevent you from going down that cycle of increased payroll to fight these claims. And it’s the perspective of fighting them the right way, fighting them aggressively, and doing so in such a way that puts to end the claim denial culture permanently in your practice.

And Tessina has direct, relevant experience—as she does that every single day for her clients.

Tessina, any—I mean, this is amazing—any closing thoughts as you wrap up today’s episode?

Final Thoughts

Tessina Bullock: I did think of one—but we’ll be quick. Just that, getting that insurance breakdown of benefits. Make sure ahead of time you are asking what the exclusions and limitations are. If an insurance company is denying a procedure based on a financial arrangement between the patient and the—or the employer and the insurance company—for a lower premium, those are harder to appeal. You can’t appeal that.

But those EOBs would say that the patient owes that portion, not that your office has to write it off. So know the difference there. Have that information ahead of time. Prepare your patients, and that will also reduce a lot of your stress.

Ben Tuinei: That’s wonderful. Wonderful. Well, folks, visit Tessa’s website, www.verisdental.com. Tessa is the leading expert in the industry on all things insurance, and her company provides coaching, insurance verifications, insurance negotiations, and all that fun stuff. Pretty much anything as it pertains to dealing with insurance—either she could do it or give you a good resource. And she’s a really, really, really solid, trusted expert on all these matters.

And Tessa, I just want to thank you again for your wisdom and for your feedback. And to our listeners, visit her website, verisdental.com. Find that in the show notes if you’re driving or otherwise preoccupied. Thanks again, Tessina.

Tessina Bullock: Thank you.

Ben Tuinei: So great chatting with you. And to our listeners, thanks for joining us again on another amazing episode of the Insurance Untangled podcast. Like us, review us, give us some love—that’ll help other doctors find the content as well as insurance coordinators and office managers find this relevant content that hopefully would help them too.

But until we meet next time, folks, we wish all of you the best of success. Take care now.