Why Dentists Are Going Out of Network with Dental Insurance

Narrator 1: Are you looking to grow your dental practice and attract top-tier new patients? Discover the potential of digital marketing with a personalized strategy session. Join Lila Stone, the marketing director at Ekwa, for an exclusive 90-minute consultation. Lila and her team will dedicate six hours before your meeting to create a customized marketing plan specifically for your practice. This valuable opportunity is free of charge and comes with no commitments. Visit www.insuranceuntangled.org/msm to schedule your meeting with Lila today. You’ll also receive a free analysis report so you can start transforming your practice through the power of digital marketing.

Narrator 2: 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 that is developed to helping practices like yours untangle yourselves from the mess of dealing with insurance. So we talk about all kinds of topics, and insurance is one that we love to hate to talk about. So buckle up and strap in. We’re gonna talk about something fun with insurance today. I have my colleague and co-host Tessa with me. Tessina, how are you?

Tessina Bullock: Good, thank you. How are you?

Ben Tuinei: So everybody knows who you are, Tessa. And so I’d say let’s just dive right into the content, okay? So what we wanna talk about today is a topic surrounding why doctors are going out of network with dental insurance to begin with. Like, what are doctors thinking? Like, what is going through their mind, right? So what’s motivated this topic is, I was just joking with Tessina a few minutes ago that this year I received eight different lawsuits from eight—well, two incidents from the same insurance company, but seven from different insurance companies. And so every year we get eight to fifteen, sometimes twenty different lawsuit threats, and it’s all surrounding insurance companies not wanting us to be vocal about what we’re talking about—the fact that out of network is pretty good for practices, right? And the data indicates that and supports that. And we’ve been reporting just the truth of things.

Ben Tuinei: And it’s so unfortunate that, you know, where you live, Tess, in Orem, we had that unfortunate incident at Utah Valley University a few weeks ago. Oh, and it’s—that was a crime initiated based upon a difference of opinion, right? And that’s what we’ve been getting. Unfortunately, the insurance companies haven’t fired any actual shots at us, and I say that very respectfully because the insurance companies have been following the right protocols to fight people like us, and I respect that game. I respect it. What I don’t respect is when violence is inserted here, and I hope we never get to that with our careers. We’ll never initiate it, but you just never know how other people are gonna respond. And so today’s episode—’cause I know insurance people are gonna be listening to this—is that all we’re doing is reporting what doctors are saying and where their mindset is at in terms of why the insurance industry has failed them and failed the patients, for that matter, right?

Ben Tuinei: In the sense that it was the doctors that created this concept of a dental benefit to help improve treatment, at least encourage people to see a doctor more often, right? So the intent of designing dental insurance back in the 1950s, working with the unions, had honorable intent, right? It was totally a great mission to increase utilization, give a mechanism to allow people to focus on their dentistry a lot more than they did in the past, right? And we still need to do better at that. But the design of dental insurance has shifted over the last, gosh, 30-plus years, in the sense that it’s been less about taking care of people and more about making money, right? More about creating a prospectus that looks good on Wall Street for investors, right? Not necessarily what’s gonna give Joe, what’s gonna give Jill, what’s gonna give Susie the best oral health possible.

Ben Tuinei: Right? So, with that said, just to kind of lay the foundation of today’s episode, we want to report what doctors are saying so that other doctors, as well as the insurance industry, start to understand the why behind this wave of out-of-network that we’re seeing today. So, Tessina, let’s start first with the top three things, and then we’re gonna explain each of those three things individually. But do you mind mentioning, or at least going through, what are some of the top three things that you’re seeing as reasons as to why doctors are abandoning their in-network agreements?

Tessina Bullock: Yeah, definitely. This is obviously the main baseline of where everything stems from. These doctors are frustrated, they’re overwhelmed, they’re frustrated. The patients are likewise frustrated, and everybody is saying, well, what can we do, and who can help us if nobody can help us? An example is SRP denials. We have seen a huge rise in SRP denials—not to mention all the denials we’ve had in the past. I’m not even addressing all those, just SRP denials right now.

What has been very interesting—and that thousands and thousands of doctors are reporting on—is that the bone loss is visible in the x-ray. They have measured it for the insurance company, and the insurance company’s denial states that there is no bone loss. Not insufficient bone loss—no bone loss. Or in some cases, they have said, well, the bone loss has to be specifically this many millimeters of bone loss.

Tessina Bullock: But that’s not anywhere in their guideline documentation until after you get the denial. Then they say it’s in your contract that it has to be three millimeters of bone loss, and you’re like, well, if they’ve got six millimeters, they’ve gotta go to a periodontal specialist. But yeah, they’re losing those. Sometimes they have these restrictions of what the bone loss is. Most of them do not state it. I mentioned one had said a specific millimeter measurement of bone loss, but the majority do not state a specific measurement because you can’t. The AAP and ADA have different guidelines. It’s not just bone loss; it’s not just perio pockets. It’s a combination of factors, including the patient’s medical health. All of this can be presented to the insurance company, and they don’t care about all of those factors being pulled together.

Tessina Bullock: They target specifically the bone loss. And even when we can show that the bone loss is there, they just blatantly say it’s not there. We have gone to the insurance commissioner, and the insurance commissioner says, well, we’re not dentists; we can’t argue with the insurance company or your doctor about whether or not there’s bone loss there. So my question, my call, right, is like—well, who gets the say? It’s supposed to be the dental practices, but there are some struggles in that because they’re saying they had a clinical dentist review it, and our dentist is reviewing it, and we have a difference of opinion on whether or not that bone loss is there and is sufficient for SRP. But it doesn’t matter when the insurance company is restricting that to such made-up guidelines. And the insurance commissioner has said, if you’re not happy with those contract guidelines, then your only option is to go out of network—because you signed a contract with them agreeing to that. Sorry. And I jumbled a couple of things in there too, like the insurance commissioner.

Ben Tuinei: Yeah, no, I think that’s great, Tessa. I’m making notes on this, and I’m thinking, holy smokes, it’s a lot. Yeah, this issue is getting worse. You’d think that it would’ve gotten better. And here’s an example—about ten years ago, all the studies on the percentage of people in the United States that had periodontal disease indicated that it was over 50% of all adults, right? Well, guess where that stands today?

So, I’m pulling this up live from the National Institute of Dental and Craniofacial Research—a very reputable website in terms of research on these issues. They’re saying that about 42% of adults aged 30 and above in the United States have gum disease or periodontitis, whereas a decade ago it was over 50%.

Now, we’re working through the numbers here, but if the indication of this is that patients are getting healthier as a result of the actions of a dentist, that’s what we want as a dental community, right? We want to get people in a better state of health. So when an insurance company says, “Hey, they don’t have periodontitis,” or, “There’s no bone loss there,” I guess the key question is, Tessa—who’s actually legally entitled to diagnose dentistry under that setting? The doctor that examined the patient, or the insurance company?

Tessina Bullock: The doctor is the one legally allowed to diagnose treatment, not the consulting dentist. The difficulty with these contracts—I guess maybe I’m sometimes jumbling that—but the complex issue is that the insurance company is saying and stating that they are not basing their decision on what is medically necessary for that patient, rather on their own guidelines. So, they’re not saying they’re diagnosing—because we’ve called them out on that. We’ve said, “You guys aren’t allowed to diagnose.” And they’re like, “We’re not diagnosing whether or not this patient needs SRP. In fact, we agree this patient needs SRP, but our plan doesn’t cover it because it doesn’t have the right bone loss.”

Ben Tuinei: Mm-hmm. The right amount of bone loss.

Tessina Bullock: Right? Yeah, the right amount of bone loss—which is made up from time to time. So yeah, that’s that contract restriction. We’re talking about why doctors are wanting to drop contracts, and it’s because they’re fighting that battle. A non-contracted provider doesn’t have that language to adhere to, and they’re getting their SRPs covered without those problems.

Ben Tuinei: Yeah. So I guess a big key question is—you have insurance companies that are agreeing that, yeah, the patient needs the appropriate treatment that you’re recommending, but they’re not gonna cover it because their policy says otherwise. So, as a doctor, I mean, I wish—and maybe we should do this—I wish every dentist out there that’s experiencing this issue would send letters to every patient and then have the patient send a letter to their employers and say, “You guys bought a dental plan that covers periodontal treatment, and you have employees that need this treatment who probably aren’t wanting to do the treatment because their insurance isn’t going to pay the benefit.”

You need to know this as the employer, because what is that going to do to your premium in the future when you have more sick people to pay insurance for? You’re naturally going to have to pay more because your dental plan is failing you right now. And so I highly recommend that every practice pay attention to that and let the patients and the employers know that this is going on. That is a great observation, Tessa. So—

Tessina Bullock: And I will say—sorry if I—

Ben Tuinei: You’re good, go ahead.

Tessina Bullock: One more thing with those numbers from the CDC or that other study that you have reported—these numbers are false. Because what’s happening, and the insurance company will say this isn’t their intention, but doctors are pulling back on diagnosing. Or when that SRP is denied, is it being reported? Because they said it wasn’t really necessary. So these reports going out are either a lack of diagnosis because the doctor is scared that it won’t get paid for, and they don’t want the patient to have to suffer. They’ll clean the teeth the correct way and just not bill for it—they just lose out on the money.

So the reports—we’re not helping the situation. These reports are not accurate because we are not billing correctly, or the insurance company is not correctly diagnosing on their end. Not that they’re allowed to diagnose, but they’re not correctly reporting it to the CDC either. So our numbers are skewed because they are misrepresenting the true nature of what is happening among the people.

Ben Tuinei: Absolutely. Love your answer. And by the way, folks, this is not a scripted podcast—we’re just having a discussion. What you brought up, Tessa, is actually perfect. Because when you talk about that, you have to dig really deep into the ethics, right?

But I think that is cause for those that are listening to dive deeper into these particular issues. Who has the authority to diagnose? Who has the authority to tell a patient what treatment they need? And when an insurance company engages in an alternative opinion on treatment—arguably, if I were a dentist, I’d be going to the dental board and saying, “A dental consultant from an insurance company decided to challenge my diagnosis, which is now leading to a patient not believing in the condition they actually have.”

And if the patient does not do the treatment, they’re going to lose their teeth, right? How do I fight this when other parties that are not licensed to do dentistry—to diagnose dentistry—are getting involved? But going out of network, I think, is a good solution. We need to report these things. We need to fight them a little bit harder.

And you mentioned the statistics—let me just read that again. Forty-two percent of U.S. adults aged 30 and above have periodontitis. You’re absolutely correct. In my belief, when I saw this number, I was shocked. Like, that’s way lower than what it actually is. And I didn’t know what the answer was, but you just mentioned it—we’re underreporting. We’re engaging in supervised neglect, opening ourselves up for liability by doing the treatment and not reporting it to insurance. So if you’re doing that, talk to one of us so we can get you out of that.

Tessina Bullock: Yeah, don’t do that. And also, don’t shy away from it. Sadly, the hygienists or the offices sometimes are saying it and are not treating it—out of fear driven by the insurance tactics and policies. They’re too afraid to try to report correctly because of how it will negatively affect the patient. So they think that they’re protecting the patient, but they’re not. And they’re not helping anything right now because all of our reports are off.

Ben Tuinei: Right, right. No, I love that. I love that. Okay, so that’s one of the big reasons—this no-bone-loss issue and the fact that the insurance companies have blatantly said, “We don’t really—yeah, the patient needs it, but we’re still not gonna cover it because there’s no bone loss.” Right. Okay, so what’s reason number two as to why doctors are going out of network?

Tessina Bullock: Yes. Let me think about that. It’s going to be those contract restrictions still. I think I was telling you a couple that I thought of recently—one of them is crown coverage. There are a lot of these that we see, but it’s hard to know ahead of time. Those insurance breakdowns are really, really important. When you guys are asking for coverage for a service, don’t just ask what percentage or what frequency. We have to ask about the specific guidelines and restrictions for each procedure.

So, if a patient goes in for a broken tooth and they need that tooth fixed that day—and that’s what’s medically best for them—we can look at this just like when a bone graft and extraction are done on the same day. A limited exam is covered, and a crown is covered, and that patient has a front tooth—they have work that day, they’ve got to get back to work. The doctor can repair that, get that temporary on, and they can get to work making money, then come back another day to put the permanent crown on. In some cases, it’s same-day crowns.

However, the insurance company will deny the limited exam, stating that it was done the same day, and the patient is responsible for it. So the office can get payment, but then the patient is frustrated with the office that they weren’t told about that expense. They weren’t even aware that the limited exam would be denied if done the same day as a crown—because that’s what was best for the patient. We can’t even argue what was clinically best, what was medically necessary, because it’s in the contract restrictions, the contract guidelines. So it doesn’t matter what proof we give; they’re just like, “Hey, this is black and white, cut and dry.”

Tessina Bullock: If you bill it the same day as a crown, it’s not covered. I know a limited exam doesn’t sound like a very big expense to put on the patient, but these things add up. And it’s not just a limited exam—like I said, a bone graft is covered, but not if you do it the same day as the extraction. When is the best day to do the bone graft for that patient, medically speaking? When that surgical site is open. You have to place that bone graft at the same time. To bring them back and reopen a wound—are we hearing ourselves?

But the insurance company is clearly stating, and they’ll tell you directly, this is not based on medical necessity. This is not based on what’s in the best interest of the patient. These are their contract guidelines—for them to pay less, for them to manage their monies on their end. Right? That’s how they balance things out. They’re like, “Gosh, we can’t just pay everything they send to us; we’d probably go bankrupt.” So they have to have some restrictions on when and how they’ll pay.

Their restrictions make no sense to us—medically or ethically—but they’re not designed to. So therein comes that frustration again. How does a doctor deal with that if they can’t complain, if they can’t show proof of medical necessity, if they can’t help get the patient the coverage that they were promised? What do they do? If you go out of network, those contract restrictions are gone. That limited exam, that bone graft being done the same day as the extraction—those restrictions are gone, and that coverage is now available.

Ben Tuinei: Yeah. I think the reason why all these things go on, Tessa—because you’re right, it’s a lot more than that. Like pulp caps are bundled with restorative procedures, and it’s like, well, if you don’t do a pulp cap, how is the patient going to feel during treatment, you know? It’s these things that are not scientifically in line with the benefit structure.

And the reason behind why these things are happening is because of the whole concept of assignment of benefit. When doctors started accepting assignment of benefit, the insurance companies knew that the rate of complaint about the plan design would be limited. The employers wouldn’t be complaining—it would be the doctors complaining about the plan design. But who needs to complain about the plan design in order to affect change? Well, the client does—the employer does.

Ben Tuinei: Right? And so assignment of benefit was intended to shield the employers from how poorly their plan designs were written and how badly the insurance is being processed in terms of doing the right thing to get the patient healthier. And when you look at it from an employer perspective, we give employees a credit when they don’t smoke or don’t drink, right? We give them a gym benefit if they don’t have a gym membership. We want people to be healthy.

We give them health insurance, dental insurance, vision insurance—why? Because as an employer, number one, I want to have good employee retention, but I also want my people to be healthy so they can do their work and stay with us long term. And as they stay with us long term, there’s value with tenure—in the sense that the most senior people at any organization, the ones that know things, they’re the most valuable, and you want to keep them healthy.

Ben Tuinei: Right? So the employers don’t know that. And that’s because of assignment of benefit. So employers don’t know that there are things like D0140 that should be paid for but aren’t being paid for. And what does that do in terms of the culture of dentistry? Sadly—and I don’t mean to offend doctors when I say this because it’s absolutely true—you get a culture of overdiagnosing treatment, you get a culture of overbilling.

And that’s why overbilling laws are becoming a major concern. It’s not just dentistry—it’s medicine, it’s every subset. And when you’re filing claims, you have people that are just trying to figure out how to survive, and so they make up treatment. And we just need to do better overall, because I feel like the current design needs to change—to allow for benefits to be paid fairly, to encourage doctors, to pay doctors, and unfortunately, the vast majority of doctors are honest—to pay them for their hard work, to avoid these situations where you see a wave of them going out of network.

So, that’s wonderful. What’s the third reason here? We’ll wrap up on the third reason.

Tessina Bullock: Yes, yeah, definitely. Just another example, basically, is our buildups. Lately, this has been a problem for a long time—where the buildups get bundled together with the crowns. But we have been able to show the proof and the reasoning for the buildup to be paid separately, and that has been going very well in recent days.

Now, I’ve been seeing that in order for a buildup to be covered—again, guideline restrictions, not what the ADA says—the insurance is saying that if the tooth is not sheared off at the gum line, then the tooth doesn’t need a buildup. And that’s just not real—they’re just making that up. That’s not when you do a buildup.

But again, they’re stating it’s not based on what the patient’s needs are, not based on what the ADA says, not on what industry care standards are—just on when they want to pay for it. That’s what they’re saying: “We’re willing to pay for it when it’s this bad, and not before that.” And in some cases, those teeth can’t even be saved, right? You’re like, well, we’re not doing a buildup at that point.

Ben Tuinei: Yeah, now we’re gonna do a more expensive root canal, or now we’re gonna do more implant treatment.

Tessina Bullock: If you don’t do that buildup—if you say, “I’m not gonna do the buildup because the insurance isn’t gonna pay for it”—and you don’t provide that buildup, that tooth will break. And it will break so severely that the patient has to have much more expensive treatment. So again, what are we saying? What is the insurance company—perhaps inadvertently—doing? They are training a different level of care, a lower quality of care, and patients could be getting lesser treatment.

And I think most of our dentists are fantastic, and they do not want to do this, but they are put under pressure. They’re put under the wire, and they’re like, “I’ll try to do it, but the insurance won’t cover it.” And because they’re trying to please the patient, the patient says, “I only want to do what insurance covers.” So the doctor’s like, “I’ll try to do it without a buildup.”

Tessina Bullock: Not because he doesn’t know that’s not a good idea, but because he’s put in this pressure spot between the patient and the insurance company. And he’s like, “I’ll try it, I’ll try it for you so that you can save that money.” Right? And then the tooth breaks, and then the patient needs an extraction and an implant. That didn’t help the patient, and it really didn’t help the insurance. I don’t know if they realize that they could’ve just saved money by paying for the buildup.

But this is the direction that we’re going, and there’s this huge miscommunication and misunderstanding between the dental offices and the insurance companies. And that’s what needs to change. We need to get everybody on the same page about what is standard of care—and standard of care should be what is a covered service.

Ben Tuinei: Exactly. Exactly. So you mentioned a key thing here—in the sense that insurance companies are saying, “Well, we don’t really care what the ADA says about this particular code.” Well, the insurance companies should care, because they all sign leasing agreements with the American Dental Association and promise not to change the code definitions.

So, if you’re dealing with this as a dental office and the insurance company is denying the buildup and saying the definition of the CDT code doesn’t matter—just know that the ADA prohibits violation of coding definitions. That particular statement by an insurance company would constitute a violation of their agreement, which means they would be subject to a fine from the ADA for breaking that agreement. Because only the American Dental Association can define coding.

Ben Tuinei: But you know, at the end of the day, I think the insurance companies haven’t learned their lesson, with so many of them going out of network these days. Heck, we’re dealing with issues where some doctors accidentally signed up with Delta and a few other insurance plans. And when they sent cancellation terms before the applications were approved, only Delta came back and said, “Nope, you can’t cancel for one year.” Everybody else said, “Yeah, we’ll honor your terms.”

And it’s like—when the insurance companies treat doctors this way, and now you’re complaining that so many doctors are going out of network—go figure. You know what I mean? It’s your fault.

So, well, Tessa, this has been wonderful, and your knowledge on this stuff is unmatched. This is quite amazing. Do you have any closing thoughts to doctors as it pertains to this whole concept of understanding why doctors are going out of network with insurance these days?

Tessina Bullock: Yeah, another thing is those low reimbursement rates. That’s the only thing we didn’t talk about. That’s that big thing the insurance companies point to when they say we’re being greedy and we want more money. And dentists—we know that those low reimbursement rates, again, play into the factor of quality of care, of what we can do and what we can provide. And more so, whether they can survive financially.

The reimbursement rates have gotten so low that providers aren’t actually able to make their overhead, and it becomes a serious concern of them going bankrupt. And sadly, in some cases, suicide. That’s the worst. Please don’t do that, okay? Yes, don’t do that. If you are struggling financially and you don’t know where to go, and you’re pinned between a rock and a hard place because you can’t lose patients and the insurance reimbursement rates aren’t covering your overhead, please call a specialist. Please call somebody. Get medical help—and then also call us.

Ben Tuinei: Talk to somebody. Yeah.

Tessina Bullock: Those reimbursement rates are designed to be a marketing fee. Think about it—in any business, if you are paying a marketing fee to bring in certain patients, you want it to be cohesive and beneficial for both parties. If that reimbursement rate is terrible, you’re like, “I don’t want you to market for me. I don’t want you to bring those patients.”

And that is what I hear from office after office saying: “I’m getting a lot of patients calling in saying they have this insurance company”—I won’t say the name—and they’re like, “I don’t want that. What can I do? Can I say that we can’t take any new patients?” And you can’t, by the way. But it gets tricky in there, right? Because they’re saying, “We don’t want those patients coming in the doors; we want other patients coming in.”

Tessina Bullock: That’s not really what our doctors want to do—they want to be able to treat everybody and anybody. And so again, coming to those places of, like, what do I do? A lot of doctors right now are feeling like their only option—because we have voiced these concerns to the insurance companies, and I think we need to do that more. Tell the insurance companies about these concerns, let them know, give them the opportunity to change.

But when we’ve done that with a few in the past, they have refused to change—and that leaves the doctors with only one other option, which is to go out of network.

Ben Tuinei: Another solid reason towards going out of network. So if you’re in that spot—highly offended or displeased with the current rates that you’re getting from insurance—give us a call. Visit veritasdentalresources.com. We would definitely love to chat with you to see if there’s an opportunity to help at least address the low fee schedule concerns. But in the end, if you want to go out of network, we have all kinds of resources there as well to help you, including our partners—Gary Takas with one of our sister podcasts on the same network that teaches these things.

Any which way you decide to go, let us know. We can set you up with the right professionals that can assist you there. Tessina, thank you so much for your wisdom. Always great chatting with you.

Ben Tuinei: Always great picking your brain. Thank you. And I’m sure we’ll see you on another episode of Insurance Untangled. And of course, Tessina—as long as she’s willing—she’ll be on all the Insurance Untangled episodes, and we’ll bring in and beef up some more experts for the next upcoming one. A lot of our experts weren’t available for this last one, but I promise we’ll deliver more in the upcoming webinars.

Folks, thank you again. Visit insuranceuntangled.com for perks as well as recordings—past recordings of webinars are all available on insuranceuntangled.com. Until we meet next time, we wish all of you the best of success. Take care now.