The Dental Billing Podcast

3 Things Every Dental Biller Should Know About the Insurance Commissioner

• Ericka Aguilar • Season 12 • Episode 2

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Dental insurance companies often deny necessary treatment claims not because they should, but because they can—and we explore how to fight back effectively through appeals and regulatory complaints.

• 59% of denied claims are upheld simply because no appeal is ever filed
• Unreasonable denials occur when patients have benefits but claims are still denied
• State insurance commissioners can investigate denials and prompt payment violations
• Understanding the difference between fully-insured and self-funded (ERISA) plans
• For self-funded plans, complaints must go to the Department of Labor (866-444-3272)
• Gather evidence including denials, submission reports, and clinical notes
• Position your complaint as patient advocacy rather than financial recovery
• Insurance companies cannot dictate treatment or force doctors to work for free

Remember: You're not just a biller—you are the patient advocate and the system of checks and balances they didn't see coming.


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Perio performance formula:

(D4341+D4342+D4346+D4355+D4910)/(D4341+D4342+D4346+D4355+D4910+D1110)





Speaker 1:

Let me paint a picture. You have a new patient. We do a comprehensive exam, some x-rays, we see signs of perio. Doctor diagnoses SRPs because the patient has six millimeter pockets bleeding and bone loss. We do SRPs, we submit the claim for SRPs and then comes the denial and you're scratching your head because you're thinking this patient clearly has perio. This claim was not denied for the reasons. You think. This claim was denied because policy matters more than the patient, according to the insurance companies. That's the message that the insurance company is sending. So what do they do? They remap or deny, because when the insurance company denies care that is medically necessary, they're not just denying a code, they're denying access to health. And you have to remember you're not just the biller, you are the patient advocate.

Speaker 1:

Friends, welcome back to another episode of the Dental Billing Podcast. I am your host, erika Aguilar, and today we are talking about what happens when a claim is denied, not because it should be, but because the insurance company simply can. And, more importantly, we're talking about what you can do about it. So first let me talk about a statistic that I shared with a study club I spoke at not too long ago, west Palm Beach. It was super nice, super fun. I shared a statistic and everyone in the room was shocked, and I hope this shocks you as well. In 2024, 59% of denied claims were upheld because no appeal was ever filed. That is shocking. That's not good to say the least. Right blocking that's not good to say the least. Right 59%. I'm going to say that again for the people in the back 59% of denied claims were upheld because no appeal was ever filed. And when I took it a step further, after learning about that stat, I surveyed billers. I only surveyed 10. Of the 10 billers that I surveyed, only seven of those billers I'm sorry, reverse three of those billers claimed that they regularly appeal unreasonable denials.

Speaker 1:

We can't do anything about frequency limitations for things that you didn't check. If you didn't know that the patient wasn't eligible for an FMX, that's on you and by you I mean whoever you are that needs to be checking the insurance benefits, doing a proper verification. We can't really do anything about that. That's just something that either the office is going to eat or we're going to charge the patient. However, we can do something about unreasonable denials. What is an unreasonable denial? It's when the patient has benefits that are available to them. Let's talk about SRPs. Perio is a covered benefit, 4341 is a covered benefit. You can do all four quads in one visit if you choose to do so. We have met the criteria for payment and the claim still gets denied. Friends, that is the quintessential unreasonable denial. We have to get better at not allowing insurance companies to get away with stuff like that. 59% of denied claims were upheld because nobody bothered to appeal them. Let that sink in a little bit and let's move on to why dental billers need to know about the state insurance commissioner. So I just talked about appealing. We got to do better with appeals. But what happens when your appeal is denied? That denial is upheld? Well, we need to know about our state insurance commissioner because they are one of the only regulatory bodies that has the power to investigate and enforce against this unethical, unreasonable denial insurance behavior, delay tactic behavior.

Speaker 1:

When you file a complaint to the state insurance commissioner, it creates a ripple effect of accountability. Here are three reasons you need to know who your insurance commissioner is and how to contact them. Number one they can investigate unreasonable denials and prompt pay violations. Filing a complaint forces the insurance company to respond to the Department of Insurance, not to us. It's a legal response to a state inquiry. Number two you can protect the patient from wrongful benefit loss. Patients trust your office to help them access the care that they have rights to. When you file a complaint and help the patient to get involved in the process, you're not just filing paperwork. You're standing up for your patient's right to treatment. Number three you create a pattern of accountability. One complaint may not move the needle, but when multiple providers are filing a complaint about the same carrier or tactic, it sets off red flags that lead to things like fines, investigations and, ultimately, friends change. That's what we're trying to accomplish here. But what happens when the insurance commissioner says, sorry, it's not under our jurisdiction? I get this question a lot in the live workshops that I do specifically around denial management and what to do when the insurance companies are unreasonably denying. I call it denial management. And what to do when the insurance companies are unreasonably denying I call it denial management.

Speaker 1:

This is when we have to know the difference between fully insured plans and self-funded plans. I did a podcast episode on the difference between the two. I'll put a link to that episode in the show notes. These are usually referred to as self-funded plans, also known as ERISA plans. These are plans sponsored by large employers. The Home Depot is an example of that. The Home Depot utilizes their own funds to pay for their dental claims and, specifically, they're using the funds of their employees' retirement. So, because they're using retirement funds to pay medical and dental claims, the agency that's going to oversee this is actually the Department of Labor. This is a federal process. So now we've gone from state and the state saying we don't get involved in self-funded plans. You need to take this to the Department of Labor.

Speaker 1:

When you're talking about a self-funded plan, you're not going to get a check from the Home Depot. You are going to receive a check from MetLife, because MetLife is the third party administrator for the Home Depot, meaning that the Home Depot designed their own plan and what they are going to cover and they are allowing MetLife to manage that fund and that plan, making sure that it's compliant, it's not violating any federal or state laws, and that's what MetLife is responsible for. That's what the Home Depot is paying MetLife for to provide administrative services only. You will see that most of the time on the patient's insurance card You'll see something like administrative services only, but you are calling MetLife to get a breakdown of benefits. You are attaching MetLife's fee schedule right.

Speaker 1:

So we have to be aware of when we are appealing a self-funded plan versus a fully insured plan, because you also have MetLife plans that are fully insured, meaning they are not using the funds from a employer. Metlife is assuming responsibility for the claim, whereas MetLife, as a third party administrator, is not assuming financial responsibility for that claim. The Home Depot is for that claim, the Home Depot is. So when we receive an unreasonable denial, the first question is who do I go to? Which regulatory body am I going to go to in order to file a complaint? And once you understand which regulatory body to go to, it's either going to be the state insurance commissioner or it's going to be the Department of Labor. So when we file a complaint with a self-funded plan, we have to follow a different process. So the first thing that the federal process requires is that you do submit internal appeals, both first and second level, with the insurance plan, with the plan, the self funded plan, because you still have to give the plan an opportunity to make this right If the benefits are available and there's funds available and we have given the insurance plan sufficient evidence proving dental and or medical necessity. They need to have a right to pay that claim. But let's just say that you took it to the second level appeal and it was upheld. The denial was upheld and it was upheld. The denial was upheld.

Speaker 1:

You then want to, if you haven't already done so, request a copy of the summary plan description from the employer's HR department. Patients have a legal right to this document. It outlines what's covered and how it's covered. No-transcript. You then want to file a complaint with the US Department of Labor. When you reach out to the US Department of Labor, you're going to want to speak to the Employee Benefits Security Administration, the EBSA. I'm going to give you their direct hotline and I want you to put that in your back pocket. Have it just in case you need it. But you're going to reach out directly to the EBSA hotline. The number is 866-444-3272. 8272.

Speaker 1:

When you reach out to the EBSA hotline, you're going to be connected to a rep that is going to help you follow the proper steps. Before you do that, you're going to need documentation of either the first and second appeal or the first appeal. You're just going to need documentation of appeals. You're going to need a copy of the denial, supporting records and all of that sufficient, all of that evidence that you have proving that the treatment was necessary, and you're going to want to have a copy of the summary plan description because they're going to want to see that Once you reach out to the EBSA, they're going to help you as the provider or the biller and or patient through all of the next steps. So don't let out of jurisdiction stop you. So don't let out of jurisdiction stop you. It means that you have to take the fight federal, when the plan is regulated by the state's insurance commissioner and you file a complaint.

Speaker 1:

What happens behind the scenes is interesting. An investigator is assigned to your complaint and that investigator is going to notify the insurance company that you filed a complaint on behalf of this patient and your complaint is, as an example, unreasonable denial. The insurance company is going to have to respond to that complaint in writing and if they've broken a law either the prompt pay law this was a bad denial, so they're going to make them pay it or there was any type of unfair practices discovered, the insurance company can be fined. I've personally been a part of that. They can be forced to pay the claim. I've been a part of that, or they can even be referred to more legal action. I want you to hear this and I want to say this loud enough for the people in the back. We have seen it happen. We've seen fines issued, we have seen claims reprocessed and we've seen plenty of offices win.

Speaker 1:

But, friends, you have to fight. So here is what you're going to want to do. One you need to know the rules in your state. In California, prompt pay says that insurance companies have 40 days to pay a clean claim. Know the definition of a clean claim. You need to gather your proof.

Speaker 1:

Whether you're going through the Department of Labor or you're going through the State Insurance Commission, you need to make sure that you have your ducks in a row. Make sure that you've got your denial, your EOB, your submission reports from the clearinghouses, the clinical notes. You want to have everything prepared and packaged properly so that you can prove that the insurance company is unreasonably denying benefits to the patient, and this is very important. When you are getting the insurance commissioner involved or you're contacting the employee benefits security admission, I want you to keep in mind that these are for patients. These hotlines and these processes are designed to get the patients the benefits they're entitled to. When you lead this process with they're denying my claim and you're just all about the money and not about your patient, you kind of lose the attention. So make sure that you are advocating for your patient, because that's what these regulatory bodies are designed for. They are designed to protect your patient's rights to health, and you want to make sure that that's exactly what you're doing when you're reaching out to these regulatory bodies.

Speaker 1:

You want to then file your complaint. Once you've gathered all of your evidence, you want to then file your complaint with your Department of Insurance or ERISA, with the Department of Labor. Encourage your patient to file their own complaint, because their voice matters too. Insurance companies cannot force our doctors to work for free. They cannot dictate what treatment a licensed dentist performs. They cannot continue to profit off of denials just because we're too busy. You're not just a biller, you are the advocate. You are the system of checks and balances they didn't see coming. It's time that we start acting like advocates and not like billers. Thanks for tuning in, friends. I hope that this episode resonated with you. I want you to win and I want you to advocate for your patients. That is it for this episode. It's a shorty episode but it's powerful and I hope that you learn how to better advocate for your patients. Now go be great, and I will see you in the next episode.

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Ericka Aguilar

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