Built to Get Paid Series - Part 6 - Denial Management & Escalation that Works

Less than 1% of denied dental claims ever get appealed and insurance companies are counting on you to be in the other 99%. I walk you through the denial management mindset shift that changes everything: stop treating the third appeal like the edge of the map and start using the tools that actually hold payers accountable, including your state insurance commissioner for fully insured plans. 

We get practical and specific about what makes a denial “unreasonable” or “bad faith” and how to spot the pattern: benefits are active, eligibility is confirmed, documentation supports dental necessity, and the claim still comes back denied. I also explain why we start with state and federal laws before we obsess over codes, because language like prompt pay, network leasing, and silent PPO issues gives your conversations more weight. Then we clean up common risk areas by separating an honest mistake, a contract violation, and fraud, because mixing those up can put a practice in real trouble. 

From there, we talk tactics: why copy-and-paste appeal templates can work against you in a world where insurers use AI to review claims, and what to use instead. Think ICD-10 diagnosis codes, strong narratives, and patient-specific clinical details that make your claim defensible. Finally, I share documented enforcement examples, including a major fine tied to undisclosed “phantom” frequency limits, and why complaints to regulators compound over time. 

If you want a denial process that protects patients and stops leaving money on the table, listen all the way through, then subscribe, share this with your office team, and leave a review so more billers learn how to escalate the right way.

Sources referenced in this episode:

• Appeal rate / upheld rate: KFF analysis of CMS data — fewer than 1% of denied ACA marketplace claims are appealed; insurers uphold ~56% of appeals (2023 data), 66% (2024 data). Medicare Advantage: ~57% of appealed denials overturned. (On air we used these instead of the "59% upheld because nobody appealed" framing, which conflated the appeal rate with the uphold-on-appeal rate.)
• Delta Dental of Washington: Washington State Office of the Insurance Commissioner fined Delta Dental + its health care benefits manager (Wyssta) $130,000 (Oct/Nov 2024) for, among other things, denying claims based on time/frequency limits not filed with or approved by the state; 7 service types and 50 billing codes had undisclosed limits. Triggered by consumer complaints. This is an actual regulatory fine.
• Self-funded vs. fully insured (the "federal path" mention): The commissioner regulates fully insured plans. Self-funded employer plans fall under federal ERISA law and route to the U.S. Department of Labor (EBSA) instead, not the state commissioner. This is covered in depth in the full denial management talk, not this episode. (Government and church plans are a further exception.)
• Cigna PxDx: 2023 class action (E.D. Cal.), citing ProPublica reporting — ~300,000 denials in two months, avg. 1.2 seconds per claim, "we literally click and submit." Court allowed the case to proceed March 2025 (abuse of discretion). This is litigation, not a fine — described on air as a lawsuit/court ruling.
• UnitedHealth nH Predict: Class action (D. Minn.) alleging a 90% error rate on the AI tool and that ~0.2% of policyholders appeal. Court ordered algorithm disclosure in 2026. Allegations in active litigation — stated as such on air.
• The "0.2% will appeal" motive appears in both the Cigna and UnitedHealth complaints as an allegation of intent.

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Transcript

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SPEAKER_00 0:22

Hi friends, welcome back to another episode of the Dental Billing Podcast. I'm your host, Erica Aguilar, and in today's episode, I want to talk a little bit about denial management and the power of the insurance commissioner. It's kind of like a mini masterclass, a condensed version of my signature talk. It's what I'm known for when I speak at study clubs and dental associations and at my own events. We spend a lot of time talking about the power of the insurance commissioner, how to switch up or change up your denial management strategies so that we teach the insurance companies how to treat our office as opposed

Why Denials Keep Winning

SPEAKER_00 1:08

to them designing all of these mazes to keep us in the dark and lost. Here's a number I want you to sit with before we get into anything else. Less than 1%. That's how many denied claims ever get appealed. Not 10%, less than 1%. And the insurance companies know this. They have built their entire denial strategy around that number. They're betting every single day that you will get a denial and either write it off or bill the patient and move on. They are counting on us to quit. So today we're going to talk about how to fight fire with fire. If you've ever been to one of my live workshops, you've heard me say, we fight fire with water guns. Insurance companies use fire and we fight back with water guns. When I go into an office, a lot of times we are talking about rebuilding or building out your billing department. And most offices, most doctors don't realize that they have a billing department. And if you don't even know you have a billing department, then you're not treating your billing department like a business within a business because it really is. And a lot of times people think that we're going to start with codes and attachments and how to incorporate codes that we're not using. And I get that question all the time. Are there any codes that you suggest we use that maybe we're not using? And yes, we can have that conversation too. I did release, I believe on TikTok, I made a post about the most underutilized codes in dentistry. And then I released a free download. I believe it's in our show notes as well, is the top underutilized codes in dentistry and how to get them paid. That is, you should have a link to that in my show notes. But a lot of people think that we're gonna start there, and we don't. We actually start with state and federal laws, and then we talk about how to incorporate those laws into the billing process. Let me share something with you that I hear over and over again. And this is specifically about denial management. When I interview billers for fortune, I ask them to walk me through their specific denial management process. I want to know when do you make the decision to appeal? And I've heard various definitions, various answers as to when one will appeal versus another. Some people don't appeal ever, believe it or not. And they actually say that in the interview and they'll say, Well, I have never done an appeal. If something gets denied, I just bill the patient. And that is definitely not advocating for your patient. And that's a whole other topic that we can talk about later. But when I interview them, I ask them to walk me through their denial management process. Now, these are good billers. These are people that have been doing billing for 10, 15 years, and almost a hundred percent of the time, their stories end about the same way. They do one, two, three appeals, and then the denial is upheld. And at that point, they make a decision to write it off or bill the patient. For them, that's where their denial management process ends. It's at the third appeal. It's almost like the edge of the map for most billers. In all my years doing billing, and I have been a biller since 1998, I can count on both of my hands the amount of billers who have told me they took a claim to the state's insurance commissioner and filed a complaint against the insurance company. That is scary to a lot of people. And one of the things that comes up in the workshops is retaliation by the insurance companies. Dentists are afraid to file complaints against insurance companies with the state's insurance commissioner because they fear retaliation or that there's going to be a tick up of denials because the insurance company is going to retaliate. That has never been documented. I've never heard of an insurance company retaliating. And there are laws around you filing a complaint that protect you, that insurance companies don't want to get found violating. So just know that right out the gate, filing a complaint with your state insurance commissioner is not going to cause retaliation. I don't know where that rumor got started. I just know that I read a lot of the insurance commissioner audits and what insurance companies get fined for. And I've never heard of a case where the insurance company was being sued or was retaliating against a specific dental practice. So I just want to put everyone's mind to ease that using the method that I'm going to talk about in today's episode does not come with retaliation from the insurance company. And don't listen to anybody that ever tells you that that can happen because there are so many laws that protect you that we won't get into right now. Okay, so having said that, I want to tell you that we have to go beyond the appeal if we want to have change in billing, specifically in dentistry. Filing a complaint with your state's insurance commissioner is something that I think most billers were never taught because first and foremost, they were never taught their state and federal laws. And knowing your state and federal laws changes the game as a patient advocate for all of your patients, right? So when you know your state and federal laws, it you see a much clearer

Fear Of Retaliation Debunked

SPEAKER_00 7:31

path as to how you can advocate and fight for the benefits that the patients are paying premiums on, but not receiving the benefits. And when you file that complaint, those complaints compound. It's like compounding interest. And when there are a ridiculous amount of complaints on file for a particular plan, that's gonna cause a different type of investigation. Your complaint, your single complaint, will be investigated. But when the insurance commissioner says, why do we have 300 complaints from Delta by Delta from providers by Delta Dental, we should probably look into that. So they will look into specific cases where the insurance company has violated in a certain region multiple times and then find that Delta Dental, as an example, has in fact done some underhanded things that they should have fixed. I'm gonna talk about one of the most recent Delta Dental of Washington cases later in this episode because I want to back this episode up with evidence, which is why I'm gonna put all of my sources, my links, the links to the resources that I used for research if to create this episode so that you can go and read the same information that I read when I was doing my research. Okay, so when I go into an office and we are talking about restructuring, reorganizing, systemizing the billing department, the office is usually surprised when I say, okay, let's talk about state and federal laws. And I want to make it clear without knowing your laws, you cannot advocate for your patient. You need to understand prompt pay time frames. You need to understand what is the difference between network sharing and network leasing and the laws around them, the silent PPO problem. So you know when a plan is renting access to another network that never negotiated with you. You need to know what anti-kickback laws actually prohibit and how they get violated. Because when you know how to use this language, your conversations carry more weight

Know Laws Before Codes

SPEAKER_00 10:06

when you use these terms correctly. And I would also say that it's important for a biller to know the difference between three things people in this industry throw around constantly and get wrong, especially when it comes to their own office. A simple mistake, a contract violation, and fraud. Those are not the same definitions. They do not carry the same weight, and confusing them can put a practice in trouble. A simple mistake is an honest error with no intent behind it, you guys. You build the wrong tooth number. A date of service got fat fingered on the keyboard, so we entered the wrong date of service. A claim went out to last year's plan instead of this year's active one. It happens in every office on the planet. Like there's no scheme, there's no deception. You catch it, you correct it, you resubmit, or you update the patient's health history to the correct tooth

Mistake Versus Violation Versus Fraud

SPEAKER_00 12:52

number. But the gray area, the part that trips people up, a mistake only stays a mistake until you notice it. The first time the software auto-populates a code that pays a little better than what you actually did, and you let it ride because hey, it went through, that is not a mistake anymore. And that's because you knew the line between a mistake and something uglier is the moment you become aware and choose to not fix anything. So an honest mistake needs to be fixed and it needs to be fixed fast. A contract violation is a completely different animal. And here's the part I want you to pay attention to. This is the one that is usually on us and not the insurance company. When your office signs a participating provider agreement, the doctor agreed to a set of terms. So when you charge the patient your full UCR fee and it goes beyond your contracted fee, that is a contract violation. When you collect the full fee on a service agreed to a contracted rate, agreed, negotiated, contracted rate, because hopefully you are negotiating before you sign those contracts, you are committing to a contract violation. And here's the gray area, the one that feels generous so nobody thinks twice. When you waive a patient's copay because they're having a financial hardship, money is tight, and you do this as a routine, that is a contract violation, friends. It doesn't feel like you're breaking a rule because you feel like it should be up to me whether or not I'm going to charge the patient, but you signed a contract agreeing to charge the patient their percentage of that fee. It can kind of feel like kindness, but again, you need to collect the patient's copay and you don't want the insurance company to claw money back or terminate you over that type of pattern. Nobody sets out to deceive anyone, and that's exactly what keeps it a violation and not fraud, but it's still on you, which is why I make offices actually read the agreement they sign. Most have never seen the agreement that they have signed, and you cannot follow terms you have never looked at. So read your contracts before you sign them. Hopefully, you're having an attorney like Justin Withrow looking over those contracts because it's important that you know what you're getting yourself into. And finally, the last one that's thrown around a lot incorrectly is fraud. This is the heaviest word in our industry, and the one I think I see people sling around the loosest. Fraud is not a mistake, friends. It is not a contract violation. Fraud is knowing intentional deception for financial gain. The obvious version is billing for services that were never performed or upcoding to a bigger procedure than the one you actually did. Then there's the gray area of fraud. And this is where good people talk themselves into real trouble because in the moment it doesn't feel like fraud. It feels like you're just helping your patient. You change the date of service so it clears the waiting period. You report the work on a tooth that's covered instead of the one you actually treated. Yes, this stuff happens, you guys. I've seen it all. You split one procedure into two codes so more of it gets paid. Oh yeah, I've seen that unbundling done before. I've heard of all of them, and none of it matters. The second you knowingly misrepresent something to get a claim paid, you've crossed from working the system into fraud. It is a crime, and it will end a doctor's career. Know where the is and never let anyone in your office walk across that line because, friends, I interviewed Dr. Roy Shelburne on this podcast. I'll put a link to that episode. He is a dentist who went to prison for 19 months for $17,000. And his office manager was also indicted. Everybody got indicted. This is something you don't want to play with because I think there's a common misrepresentation about who goes to jail when fraud is committed. And it is no longer just the dentist. The biller will go to prison along with the dentist losing their license. And in Dr. Shelburne's case, it was for $17,000. The feds don't care about the amount, they care about the intent. And you have a duty to know what fraud is, and you have a duty to not do it. Even if your doctor is telling you to do it, you have a responsibility to say, I cannot do that. That is fraud. But you first have to know what fraud looks like. Okay. So I hope that clears up for you the difference between an honest mistake. We weren't, we didn't bill the wrong tooth number for financial gain. That was a mistake. Again, we fat-fingered, we fat-fingered the keyboard. So we're going to correct that by calling the insurance company and updating the patient's history to the correct tooth number. That's an honest mistake. Mistakes get fixed and they get fixed fast. Then you have your contract violation. Waiving co-payments is not fraud, but it does violate the contract. And then finally, fraud is done intentionally for financial gain. So I hope you see the distinction between those three that loosely get thrown around. And then that misunderstanding can cause problems in an office. Now, once we understand those terms, and in the workshops, we spend a lot of time going through federal and state laws, depending on the state that I'm in. It all changes state to state. We spend a lot of time. We spend most of our mornings talking about state, federal law, the difference between a simple mistake, contract violation, and fraud. And now we're going to go into pattern recognition. What is it as billers that we need to recognize in order to hone in our denial management skills? Okay, so one was state-federal law and the other things that we've already talked about. And now we're going to go into pattern recognition. This is where we talk about unreasonable denials, bad faith denials, and when to know that the insurance company has issued a bad faith, unreasonable denial. And how do we fight fire with fire? So let's first talk about the definition of an unreasonable denial. You've heard me talk about this on previous episodes, but for those of you that are new here, you have not. The definition of an unreasonable denial is when you're looking at a denial,

Spotting Unreasonable Denials

SPEAKER_00 20:38

you look at the claim and all of the evidence you submitted with the claim to support dental necessity, and it's solid. You look at the benefits and you confirm that the patient's benefits were available on that date of service, and you're still looking at a denial. Benefits were available to the patient, the patient was eligible on that date of service, and we submitted sufficient evidence proving dental necessity. Why is this claim denied? Because what you are looking at, my friends, is the quintessential definition of an unreasonable denial. This is when you recognize that pattern. Now, I want to talk about pattern recognition and how one pattern that we saw in Fortune in my billing company, and it changed how we operate completely. Before we had made it mandatory to put ICD 10 codes on every claim, we started noticing a wave of additional information requests. And when we would dig deeper, we realized that these denials were actually being denied for lack of diagnosis code. And it happened a handful of times. But if there's one thing that I pick up on really fast, it's going to be patterns. And it was enough for us to put our heads together and say maybe we should start as a company, start placing diagnosis codes on the claim form because I have been doing dental billing workshops since 2011. In 2012, the ADA changed the claim form and incorporated four areas where you can place diagnosis

Diagnosis Codes And Hidden Denials

SPEAKER_00 22:28

codes on the claim form. I am one of the very few in the dental billing arena that said, okay, if the ADA is placing a section for us to start incorporating diagnosis codes, I'm going to learn how to incorporate diagnosis codes. So I did. And I've been placing diagnosis codes on my claims since 2012-ish, 13, somewhere around there. I see the writing on the wall when my billing company is starting to receive additional information requests that if you read the underlying language, you I we had to pick up the phone and call. They wanted diagnosis codes for fillings, for crowns, for SRPs. And I can tell you with confidence, a lot of offices have probably had more denials because they didn't investigate the additional information request and didn't realize that that denial should have plainly said on the EOB lack of diagnosis code. Instead, they disguised it as additional information. So when we discovered that pattern, we decided that we are going to start placing ICD 10 codes on all of our claims because we want to avoid receiving a denial that is secretly disguised as additional information. Because we didn't have a diagnosis code on there. So we've seen a significant decrease in additional information requests because our rule of thumb as a company is to place diagnosis codes on the claim form. Now, I did create a cheat sheet for diagnosis codes and simplified the most commonly used diagnosis codes. But I do want to say this with caution. That is a cheat sheet. It is not the be-all end-all. You still need to look up the diagnosis codes, which, by the way, are in the back of the CDT book. They've been put back there for I don't know how many years, and still people don't know where to find the dental-specific diagnosis codes. So the ADA has so kindly put all the dental specific diagnosis codes in the back of the CDT book. As a dental biller, I am going to encourage everybody to go purchase an annual CDT book every year. It's released, you can start purchasing in September. I believe you get it in October or November, and you were ahead of the game with regards to any coding deletions, updates, revisions, all of that. It's available to you a couple months before the new year. So I encourage all of you to go do that. Now, pattern recognition of unreasonable denials is a skill set. We have to understand that unreasonable denials are issued in bad faith by the insurance companies. And they are fully aware of these bad faith actions that they deploy against patients, essentially, not us, because these patients are paying premiums and their benefits are getting denied. So now we have to talk about how we fight back. And this is where I lose a little patience with our industry. Again, I say this at every workshop. Insurance companies have been fighting us with fire, and we, the billers, have been fighting back with water guns. Friends, those appeal templates that get passed around in these Facebook groups, the ones you've been copying and pasting for the past 10 years, those are water guns. And I need you to stop bringing a water gun to the fight. What's happening behind the scenes with these water guns that we're using is that the insurance companies, we know they've been using AI for 20 years, but now they're using it for more and more purposes. And one of the reasons, one of the purposes that insurance companies are using AI is to review claims and appeals. AI is tracking how often a given template is

Stop Using Recycled Appeal Templates

SPEAKER_00 27:08

showing up in the billing industry, right? Across all platforms, across all insurance companies. When you send the same recycled template that 10,000 other billers have also sent in to the insurance company, your narrative, your appeal loses credibility before a human ever reads it. If a human ever reads it at all. The template that once was a shortcut, meant to be a shortcut, is now actively working against you. So what do we use instead? We use the clinical notes, the specifics of the patient's health history. If you're submitting a claim for SRPs and the patient is a smoker, or the patient has diabetes, all of that should be in your narrative. It should be mentioned in the narrative because it's specific to the patient for this date of service. And we're helping to document necessity, and we have a solid diagnosis code alongside that very specific narrative that is going to tell a better story. And that is what fighting fire with fire looks like. Those templates are water guns, friends. Okay, now you know how to spot a bogus denial. A clean, valid, properly documented with clear dental necessity and benefits were available to the patient, and still they denied it. Anyways, here's how we play the game. Not the way they designed us to play, but the way we have learned to fight and play back, right? So step one is simple. We're gonna pick up the phone if we possibly can. Call the insurance company, let them know in plain, confident language that you submitted a clean and valid claim with sufficient evidence proving dental necessity, that these benefits were available to the patient on the date of service, and that this is an unreasonable denial. We are asking the insurance companies to reconsider payment immediately. And you let them know that if that is not done, you will be reporting this matter or bringing this matter to the attention of the state's insurance commissioner. That sentence alone changes the whole, I would say, temperature of the call because you they know that you know your stuff. The phone calls that I

Call With Confidence Then Escalate

SPEAKER_00 29:59

hear get made about denials go like this. Yeah, I'm calling about this denial. We did SRPs. I'm just wanting to know why did you guys still deny? We sent in a period chart, we sent in an FMX, we sent everything in, and the insurance company will say, Well, we never received it. I promise you, when you tell them that you are willing to bring this matter to the attention of the insurance commissioner, suddenly they will find it. Suddenly they found it. Have you ever had one of those phone calls where you insist that they received it and after maybe the fifth attempt, they go, well, there it is. Because they know that you know your stuff. They picked up on it. I have also experienced the opposite. I'm not gonna lie, this doesn't work 100% of the time, you guys. So, but you have to know what you're up against. Sometimes the language works and magically they will issue payment for that denial. And there's gonna be other times when you use that verbiage and it just doesn't. And they will call your bluff and they know that less than 1% ever get appealed. So you stating that you're gonna call the insurance commissioner, they're gonna call your bluff on that too. So you have to know what tool to use and when to use it. Now, if you're on that call and the denial is upheld, then you're gonna go straight into the appeal process. But there is a game changer here. You are only gonna do one appeal before we escalate to the insurance commissioner. The maze that was created as a multi-level appeal process was designed to keep us confused. It was designed to buy the insurance company more time. It was designed to exhaust us. And now, more than ever, insurance companies are winning with this crazy maze and multi-level appeal process that they make you go through. But I want you to know that you only have to appeal one time when you're dealing with the insurance commissioner. The insurance commissioner only requires that you give the insurance company one opportunity to pay if it's a legit, valid, clean claim, the insurance company has a right to reconsider payment and say, oops, our bad, we should have paid this and make it right and pay it. Now, if they don't make it right and they uphold an unreasonable denial that you're gonna appeal one time, it continues to be upheld and denied, you will now take it over to the intent the attention of the insurance commissioner. You are not going to go through that multi-level appeal process. Now, there is a caveat to this. The insurance commissioner is the regulating body for fully insured plans. And for those of you that don't understand the difference between a fully insured plan and a self-funded plan, then go back to there's I did an episode on the difference between a fully insured plan. It was probably from 2022 or 2021. I will put a link to that episode in the show notes as well. But it's important as a biller, especially when you are talking about understanding state and federal law, it's important that you understand the difference between a fully insured plan and a self-funded plan because when you go to escalate a denial and

Fully Insured Versus Self-Funded Rules

SPEAKER_00 33:52

you assume that they all go to the state insurance commissioner, there's the requirement of one appeal is okay. But when it's a self-funded plan, you actually have to exhaust the appeal process that is designed for that plan. So I will do another episode on the difference between the appeal process for a fully insured plan versus a self-funded plan and the governing bodies or the regulatory agencies that govern keep these plans accountable because there are two avenues that you have to explore. But for the sake and intents and purposes of this episode, I want to get your mind flowing around escalation. I want to get your mind thinking about going beyond the appeal, right? So going beyond the appeal is truly advocating for patients. In the beginning of this episode, I promised you that I would use this as a masterclass, a mini masterclass. And masterclasses come with evidence. So I want to illustrate to you why escalation works and why insurance companies are so afraid of it that they built a business model around you not ever knowing how to do it. In late 2024, the state of Washington's office of the insurance commissioner fined Delta Dental of Washington and its claims administrator a combined $130,000. Now I want you to hear why they were fined because this kind of the question that billers should be asking is why do insurance companies get fined? Who find them and what are the reasons why they get fined? Insurance companies do things like Delta Dental of Washington was doing. They were denying claims based on frequency and time limitations. They were doing that for frequency and time limitations that were never mentioned

Delta Dental Fine And Phantom Limits

SPEAKER_00 36:15

in the contract. Those frequency and time limits that Delta was denying on were never disclosed to the patient in their plan documents, which means the limit they used to deny the claim did not exist in the contract that the patient actually bought. So basically, what they did is they applied a limit that was not in the plan. They denied real claims using that limit and they processed those denials as if the limit were completely legitimate. And the commissioner did not take somebody's word for it. They pulled the claims and counted. In I believe it was a window of 13 months, they found 23 claims where limits had been applied that were nowhere in the planned contract. This involved 17 patients, and they had denials over limits that didn't exist. And when the investigators widened the lens, like they zoomed out, they found seven different service types and 50 separate billing codes carrying these phantom limits. 50 codes, you guys. Limits that had never been disclosed and never approved by anyone. So I want you to sit in that for a second because that is not a glitch. It's not untired processor on a Friday afternoon. That is a denial machine running on rules, Delta Dental made up and never told a single patient about. So now go back to that frequency denial that you are about to write off. When Delta Dental or any insurance company tells you a patient has hit a frequency limitation, you now know the exact question to ask, right? Like we know to ask for frequency limitations and history, friends. So this is what gets me is that I see this so often. And I'm sure you guys are gonna agree with me, but if we all agree on this, then why is it happening so much? When you look at a breakdown of benefits, you'll see that we receive the frequency limitation, but rarely do we get the history for that frequency limitation. And when I taught dental front office to people with no background in dentistry, this is what I taught them. I always said frequency and history are sisters and they don't go anywhere without each other. So if you are getting a frequency limitation, please get the history because without having that, we could end up, you know, issuing, doing treatment that the patient is not eligible for. Now, this is that's a separate issue from what Delta Dental was doing. Delta Dental was claiming frequency limitations that didn't exist. So these procedures did not have frequency limitations that applied to them. So Delta Dental should have paid them, but did not because there was this phantom frequency limitation attached to it. On the medical side, in 2023, Cygna, following an investigation, was sued over a system called PXDX. According to that reporting, the tool let the company deny claims in enormous batches, and doctors were writing off a ridiculous amount of denials. And one former Cigna doctor, so this is a doctor that worked for Cigna, described it as we literally click and submit the denial. Over 300,000 denials in a two-month stretch. And in March, a federal court allowed that case to move forward, finding the company's approach was an abuse of its discretion. So, friends, the point I'm trying to make here is that denial is

The Real Takeaways And Next Steps

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not always legit. Are there denials out there with pure merit to it because you submitted a sloppy claim? Yes, absolutely. I think that there's claim slop out there. But when you know that you submitted a clean, valid claim and it had the diagnosis codes on it, it had a narrative that incorporated the patient's health history or any specific information that is going to create the most defensible claim and the benefits were available to the patient. You know what you're up against now. And now we're gonna fight fire with fire because now we are not going to call and ask for reconsideration. We're gonna demand it. And we're also gonna demand that if they don't reconsider for payment, we're gonna take this matter over to the insurance commissioner. And the insurance commissioner does not take kindly to denying benefits to our patients. The insurance commissioner is the patient's ultimate advocate. And as a biller, you are a patient advocate, and your job is to fight for every penny that is owed to the practice for the treatment that is being rendered because the patients are paying premiums for that treatment. So you see how it's all connected. I want to be clear none of what I just told you is me just talking. Every case that I just talked about, all the fines, every number in this episode is documented, and I've put all of it, the sources and my fact check notes in the show notes for this episode. If you are a fact finder like I am, you're gonna want to go down all the rabbit holes. So feel free, don't take my word for any of this. Go read it for yourself and then go use it in your own appeals. Go ahead and take those receipts with you. So here's what I want you to take out of this episode. Know your laws before you know your codes. Well, they're both equal, but know them both. Learn to read the pattern under the denial. Put the water gun down and stop treating the third appeal like the end of the road because the road keeps going. And at the end of it is a regulator whose entire job is to hold the insurance companies accountable. The insurance companies, friends, are truly betting that you're just gonna give up or or you're gonna be that percent of individuals who never appeal denied claims. Friends, they have built billions of dollars of strategy on the assumption that you will not pick up the phone, you will not file a complaint, and that you will not escalate. Let's prove them wrong as an industry. And I'm gonna keep saying it until it stops being true. We are done fighting fire with water guns. If this episode showed you that your denial process has gaps, that it lives in one person's head, or that it stops at the third appeal, that's exactly the work I do. Book a billing consultation call with me, and my team at Fortune Billing Solutions and I will walk you through some ways to improve your denial management strategies. The link to schedule a consultation is in the show notes, or you can also go to hello at dentalbillingdone right.com, send me an email there, and we will hop on a phone call and talk about where you can improve your billing department. Friends, I hope that this episode opened your eyes. I hope you learned something new because denial management is truly our weakest link in billing. Until the next episode, keep learning, keep being great, and I will see you then. Bye for now.