It’s not business as usual in dentistry: Dental insurance challenges

Dental patients often do not understand how their dental insurance works. Simply put, it’s partial coverage. Patients frequently refuse treatment that is not covered by insurance. Therefore, dental teams need to stress the importance of taking care of patients’ oral health to them, and how it’s linked to their systemic health. Ignoring their mouth could be deadly.

Terri Herrod Wilson, RDA, CDA, CDP, FADAA

I can’t stress this enough: It’s not business as usual in dentistry. Dentistry has changed much more rapidly recently than it did during previous years. Dental insurance, reimbursement rates, and rules and regulations are also changing. Change is challenging for a lot of people, but it’s necessary in order to progress to bigger and better things.

Ben Franklin once said, “When you’re finished changing, you’re finished.”1 John F. Kennedy said, “Change is the law of life, and those who look only to the past or present are certain to miss the future.”2 Henry Ford said one of my favorite quotes, “If you always do what you’ve always done, you’ll always get what you’ve always got.”3

One of the biggest pitfalls I see in so many dental practices is their resistance to change. I tell dental teams that the seven most expensive words in dentistry are: “We have always done it that way.” Having said that, what is your practice doing to combat all of the changes occurring in the industry, especially when it comes to dental insurance reimbursements, coding, and patient billing? How do you and your team deal with dental insurance benefits that are being reduced or becoming nonexistent?

The importance of education

Do not let insurance dictate your practice and the dental care that you provide to your patients. You and your team must get on board with patient education that begins the moment patients walk through your door. Patients must feel that the services you offer have value. Your waiting room is the most important room in your practice, so think about turning it into a dental educational showroom.

Most patients are unaware that their oral health or the lack thereof can affect their whole body, including strokes, heart attacks, cancer, premature death, Alzheimer’s, and other systemic diseases. They don’t understand the correlation between oral health and systemic health. If they did, your office would never have holes in the schedule or cancellations at the last minute.

Educate, educate, educate! Place relevance and value on each appointment at your office! Use intraoral cameras to educate patients. As far as I’m concerned, intraoral cameras are the best thing since sliced bread to give patients the full view of their oral health. Inform them that dental insurance is not really insurance! It’s merely a plan that’s in place to help offset some of their dental expenses. It’s up to you and your team to put that education and value behind your treatment plans so that you have a better case presentation-to-acceptance ratio.

How many times have you heard patients say, “If insurance doesn’t pay for this dental procedure, then I won’t have it done”? Next time this happens, ask the patient, “If you have appendicitis and your medical insurance says only half of the appendectomy is covered, what are you going to do, leave in the other half of your infected and inflamed appendix?”

Would patients risk and endanger their lives just because their insurance won’t pay for a procedure? According to a recent article on, 77% of the US population has dental benefits. Out of that 77%, 40% choose not to go to the dentist due to the costs and pain associated with their dental care.4

Another scenario I often hear about is patients refusing to have x-rays because dental insurance won’t pay for them. Here is what I recommend you ask patients: “Will you take your car to a mechanic the next time it breaks down? Then will you not allow the mechanic to open the hood to fix the engine? This is exactly what you tell the dentist to do when you refuse to have x-rays. How can a dentist fix a tooth without seeing what’s going on ‘under the hood’?”

Patients go so far as to refuse entire dental procedures because they’re not covered by their dental insurance. They don’t understand that some of these procedures could extend or even save their lives. The bottom line: we in the dental industry have failed to educate the public on the importance of their dental health.

A very stubborn patient

Allow me to share an interesting and true story. One day a new patient came into the office I managed with pain in her upper-left quadrant. She said the pain had been occurring off and on for the last six months, but she didn’t have any dental benefits left during her plan year. She had just moved to the Nashville, Tennessee, area with her husband. They had relocated one year earlier, and she’d had an implant placed at that time.

Now she refused to get an x-ray because she said her dental insurance would not pay for it. I had her sign a refusal form. The form was actually more educational than it was a piece of paper that stated she was refusing x-rays. The dentist put her on antibiotics for seven to 10 days.

About two weeks later she came back, and her pain was a lot worse. She refused dental x-rays again, but the dentist told her he could not give her any additional medicine without taking x-rays to see what was causing her pain. She finally agreed to get those “noncovered dental x-rays,” as she called them, but it was too late. She had a cancerous tumor behind the implant that had been placed a year earlier, and sadly, she died six months later. Dental insurance or the lack of coverage is literally not worth dying over.

To understand how people choose to spend their money, look at the tattoo and fingernail industries, which are both very popular. No one is filing insurance claims to get a tattoo or have a set of fingernails applied. Yet people are willing to hand over the money for these services. Unfortunately, some people still view dental services as a commodity, not a necessity. They’re willing to spend money on services where no insurance is involved that could potentially harm their health but complain about their dental services not being covered at a level they would like.

Insurance from the practice perspective

Patient education from a dental perspective is one thing. But on the other side of that are the major issues dental providers have to deal with when it comes to filing dental claims and getting reimbursed at levels that actually cover the expenses of running a dental practice. My own experiences with clients have been that PPO write-off percentages have averaged 30%–50% based on the reports from the practice management software of the dental practices I serve.

What are some of the major changes occuring with dental insurance plans today?

1. Separate deductibles being applied toward preventive services in addition to basic and major services.

2. Plans that do not count codes such as D0120, D1110, or D1120 toward the plan’s annual maximum. These codes are considered “additional benefit codes.”

3. Medicare removing Social Security numbers from insurance cards.

4. Plans decreasing the amount of reimbursements to their participating providers, which in turn is causing dentists to reconsider remaining with participating providers.

5. Insurances that won’t pay at prep date. They reimburse based on seat date or completion date.

6. Time frames for “replacement clauses” for amalgams, composites, crowns, bridges, dentures, partials, etc., which increased significantly during the past three years. Some insurance plans implemented seven- to 10-year replacement clauses.

7. Decreased coverage on panorex x-rays. Some companies went from covering the x-rays every 36 months to covering them once every 60 months or longer.

Combat these dental insurance changes with positive changes in your practice. Educate your patients with facts about how their oral health affects their overall health, and tell them that dental insurance is designed to help offset dental expenses. Encourage your patients who have insurance to use and maximize their benefits. Train your entire dental team on how to properly chart and code dental procedures.


1. Benjamin Franklin quotes. Brainy Quotes website. Accessed September 28, 2018.

2. Address in the Assembly Hall at the Paulskirche in Frankfurt. June 25, 1963. John F. Kennedy. The American Presidency Project website. Accessed September 28, 2018.

3. Henry Ford quotes. Goodreads website. Accessed September 28, 2018.

4. Gale SF. Sector report: The bright shine of dental benefits. Workforcewebsite. Published March 15, 2018. Accessed September 12, 2018.

Terri Herrod Wilson, RDA, CDA, CDP, FADAA, is a dental practice development trainer and coach. She heads up the practice and development training division for a major dental supply and equipment company. She previously worked for one of the nation’s largest managed-care organizations in Tennessee. Ms. Wilson has published many articles and served as the featured speaker for several CE seminars. Contact her at

More in Practice