Insurance Dirty Tricks and How to Battle Them

We’ve all seen them, the dirty little tricks insurance companies do to make our lives a living hell, right? At My Practice My Business our dental consulting helps practices deal with this “hell” head on with our Clinical Business of Dentistry Training. However, here is a small list of typical insurance tricks they use to torment us, and how to deal with them.

-Baked in codes:

This is one of my favorites. It’s where they tell you to include the build-up code with your crown code, therefore, giving away the build-up. If you look at your contracted fees, you will see the CDT code for build-ups with its associated fee. You contracted with their fee schedule. You do not give away your services, nor do they have the right to tell you to give it away, and that’s what you tell them. The American Dental Association actually owns the CDT Codes, they lease those codes to all the insurance companies (and practice management software companies) Therefore the insurance companies have to honor the procedures that are defined by the ADA. If an insurance company attempts to tell you how to code and what to bill, they are on the verge of practicing dentistry without a license. They know they’re treading on ground that can get them in trouble. But it’s up to you and I to keep them in check, otherwise they will try to get away with anything they can do to increase their profits and cut into ours. Simply push back, tell them you are charging for the services you provided, and either they can pay their portion or you will collect it from their client (your patient) and let them know their insurance company is trying to pull a fast one on them. In addition, are you seeing insurance companies requiring oral facial images to prove the need for the build-up?  Take the pic, and charge the patient for D0350.

-Downgrading and alluding to dental offices to write it off:

We have been seeing this with composite fillings being downgraded to the fees of amalgam fillings for years. But now we are seeing insurance companies take all porcelain crowns and downgrade them to metal crowns, or the least expensive crown on their list. The important thing to remember here is you still collect the fee from the procedure you did. You do not write off what the difference is between the composite fee and the amalgam fee. That remaining balance is the patient’s responsibility. Almost always the EOB makes it sound like, through their verbiage, that you have to write off the balance. This is not true. The insurance company will often times tell their client, your patient, that you do need to write off the balance difference. Don’t do it! You didn’t downgrade, they did. Collect your full contracted fee for the procedures you completed.

-Adding you to a lesser sister insurance plan without your consent to boost their panel:

In 2017, unknown to us, Blue Cross Blue Shield signed us up for their “Value Care” plan, which pays significantly less than their standard dental plan. We found this out the hard way when one of our new patients freaked out saying we charged them more than we should have. When we investigated what had happened, we learned we were added to the panel of dentists on the Value Care plan. Their EOB said we needed to write off additional amounts than what we had billed. We always bill out the contracted amount so we always know where our production totals are. No, insurance companies do not base their contracted rates based on our FFS/UCR fees. We discovered that fallacy many years ago. Anyway, BCBS told us they posted it on their website, and supposedly sent us an email declaring their potentially unlawful actions. Well golly gee, we should have known…. Bottom line, evaluate whether you want to stay on their lessor plan or not. And remind them it’s potentially illegal to add you to a list without your written consent.

-Covered benefits that are not covered:

What is the first thing you hear on the recording when calling an insurance company? It goes something like this: “verification of insurance is not a guarantee of benefits”. We have this patient who had recently retired from one of the major dental insurance companies, and she needed some major work done. We gave her the treatment plan, and showed her what the insurance company would pay for, and what it would not. She came unglued! She called her former employer, got the typical generic answer of what the coverage would be (which was way more than what we showed her) and she brought her notes and paperwork into our office for battle. We very kindly held our ground, and I even told her if we were off by more than $100, my wife and I would take her and her husband out to a fancy restaurant of their choice. Needless to say, we came within $67 of the treatment plan proposal. Yes, she owed us that much more, which just made her day! LOL. This whole exercise was proof positive of the waste of time we put our front office through every time we have them call to verify insurance benefits and coverage. That’s what practice management software is for, mixed in with practical experience on which insurance companies to alter the percentage of coverage on. We do major dental consulting on this topic in our Clinical Business of Dentistry Training. Bottom line is this, it’s the employer group that alters their allowed benefits to control their premium costs for dental coverage to their employees. Blame it on them!

-Policy changes without notification to you:

Don’t you love it when a patient complains about their bill because they called their insurance company, and the services you provided were not covered under their policy? With so many different insurances out there, and each one of the majors having multiple plans within their company due to employer groups changing it up to cut costs, how are you to know when they push out a change in someone’s coverage. And don’t tell me that is why you verify insurance coverage on every patient, because we know that can change at will, and you never get all the details. Just do your best, and when push comes to shove, the patient owes the balance after all we can do.

-No payment within thirty days:

In our state, insurance companies legally have to pay on a claim within thirty days from the time they receive it. Thank goodness for Dentrix e-Claims which shows when an insurance company opens up their electronic claim. Having said that, how does a little solo office go after dental insurance companies whose lobbyists have made them exempt from anti-trust and collusion laws? It’s simple, you keep accurate records and send them into your state insurance commission. They have to investigate every infraction, and if found guilty, they pay a fine for each complaint. It adds up in a hurry, and cost them money. Nail them to the state insurance commission’s wall. Sometimes you can become good friends with the investigators, and they will work your cases well, as long as you provide them with accurate evidence each time.

-Multiple fee schedules, but you get the least paying one:

When we learned of this little game many years ago, it frustrated me to no end. All the major insurance companies have multiple fee schedules just in your zip code area. So how do they determine who gets the higher fee schedule? It’s simple, the squeaky wheel gets the better fee schedule. I’m a member of the Dental Cooperative, which is a company who brings to independent dentists, many benefits. One of the best benefits is their ability to negotiate higher insurance reimbursement fee schedules for their members. And believe me, it is significantly higher. With most insurance companies, you can ask for a fee increase every two years. The most important tactic is to make sure you talk with someone in the department who manages their fee schedules.

-Verifying insurance coverage: never a guarantee

I touched on this up above. But it’s important for you to understand the investigation we did on this one topic. We called all twenty plus insurance companies we are in network with, and asked the question, “Is it necessary to verify insurance coverage on every patient?” The answers we received were nearly identical, and comments made were revealing.

First- They all said that it is recommended but not necessary. That’s right, an oxymoron. What they meant was it was recommended on new patients, and patients who may have had a change in their insurance coverage. They told us that their plans were consistent with general coverages, and if we had one patient on their plan, then the coverages would be explained the same for the new a patient. Oh sure, there were differences from time-to-time, but they were usually not significant enough to waste your time on the phone…on hold…forever sometimes…

Second- It was recommended just in case the patient had lost coverage, and might be responsible for their entire billable services.

Third- They reiterated that no conversation was a guarantee of benefits. It’s the first thing you hear on their recording when you first call, and they usually reiterate it again during your conversation.

Fourth- They are amazed at the amount of time offices spend making those phone calls just to verify coverages on procedures, especially when all practice management software has those tables built in.

Fifth- Nearly all of them commented on the fact that offices who call all the time just maintain their job security. So they said, “keep on calling”.

Well, there you have it. The truth about verifying insurance coverage. Many of you will reconsider this needless task on every patient every day. Others of you will continue the time-consuming task that isn’t a guarantee of benefits.

The dirty tricks insurance companies do never cease to amaze me. Remember, they are just a business that has to make money like every other corporation. The above are only some of the things they do to us. Sometimes I think the only reason I stay in dentistry is to see what they do next. I’m on the edge of my seat…

Rob Thorup, DDS

Clinical Director/Co-Founder

My Practice My Business


Contact Info

7138 S Highland Drive
Cottonwood Heights, UT 84121

Phone: 801.226.4420


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