What If We Called the Denial What it Really is: A Business Model Designed to Delay Payment

Less than 1% of denials get appealed in the real world, yet regulators have found appeal reversal rates that should stop every dental office in its tracks. We pull apart what that contradiction tells us: denials are not just “one-off mistakes,” they can be a business model that survives on provider exhaustion, unclear standards, and paperwork loops that quietly delay payment until you give up.

We walk through the hidden source material most billers never read market conduct examinations, consent orders, and enforcement actions where the state audits the insurance carrier and publishes what it finds. From “sequential” documentation requests to denial language that fails to explain what would make a claim payable, these reports turn gut feelings into quotable evidence. We also explain why a fine is effectively a written confession: it shows which behavior could not survive an audit and gives you leverage to reverse engineer your next appeal and escalation.

Then we get practical. Clean claim is a legal term tied to prompt pay law, and understanding it changes how you respond to additional information requests designed to stop the clock. We share two calm questions you can use immediately: ask for the filed policy provision that supports the denial, and ask which licensed clinician reviewed the claim and whether they reviewed the submitted documentation. Finally, we zoom out to pattern recognition: denial rates, overturn rates, time-to-payment, and filing complaints with the right regulator based on plan type, including ERISA self-funded plans and the US Department of Labor.

If you want smarter dental billing appeals and stronger denial management, listen now, subscribe for more, and share this with a biller who is tired of water-gun tactics. What denial pattern are you seeing most in your office?

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Transcript

The Denial Numbers That Matter

SPEAKER_00 0:46

Less than 1%. That is how many denials were ever appealed last year. Less than 1%. Now, that number is from my own research within my company. As we onboard new clients, we do quantify their denial management percentage in terms of appealing denials as they come on board. Obviously, we are appealing the denials moving forward. But less than 1% of the denials that we see get appealed in the first place. Now, I'm going to ask that you hold on to that number because I'm wanting to put another number right next to it. In Rhode Island, the state insurance regulator got a warrant, walked into Delta Dental of Rhode Island, and read Delta Dental's own appeal logs, roughly 5,700 appeals. And here is what the examiner wrote down. 79% of those appealed denials were reversed. Here are their words, not mine. Nearly eight out of every 10 denied claims that were appealed got reversed on appeal. So think about those two numbers. And what has to be true for both of those things to be true at the same time? That is not a coincidence, friends. That's a business model. And it only works because we do not show up as an industry. Hey friends, welcome back to another episode of the Dental Billing Podcast. I'm your host, Erica Aguilar. And if you are new here, this is a show where we talk about everything dental billing, compliance, law. And today we're going to talk about how to fight fire with fire. Because as an industry, insurance companies fight with fire and we fight back with water guns. Today I want to do something a little different. I have been building a workshop for the past several months, and it's been one of the hardest things I've worked on and put together. It's called Denial Management, Appeal Escalation, and the Power of the Insurance Commissioner.

Market Conduct Exams Reveal The Playbook

SPEAKER_00 3:06

It is a half-day workshop, and I want to open the door and let you see inside because I think even if you never attend that workshop, there are three things in it I need you to hear. I'm going to give you all three in this episode, and I'm also going to make a confession. For 31 years, I have been in dentistry. And for the most part, I did what you do. Most of you listening are dental billers. I worked one claim at a time. The denial comes in, I fight it. Denial comes in, I fight it. Most of the time I won. Some I had to write off. And then a few years ago, I stumbled upon market conduct examinations and I started reading up on these. And if you have never heard that phrase, just stay with me because I'm gonna explain the whole thing. A market conduct examination is when the state insurance regulator audits the insurance company, right? So we have offices who are always asking me questions like how do I prevent an audit? Well, that's when the insurance company audits a practice. This is next level. So this is when the practice files a complaint with the state insurance commissioner and the insurance commissioner or the regulatory agency that has authority to do that audit does an audit of the insurance company's behavior, for lack of a better word. Sometimes these audits happen because one complaint at a time piles up and it triggers an audit of the insurance company. So if they have one complaint for one patient and suddenly they have 300 similar complaints, sometimes it could be 10 similar complaints, they will then audit the insurance company. And we're gonna talk about that a little bit later in this episode. And sometimes these audits happen as a result of a whistleblower. When this happens, an examiner goes in and reads the insurance carrier's own files. They read the appeal logs, the denial logs, the customer service call sheets, and all of the insurance company's internal notes. And then they write down what they find and they publish it on the state's website. I had been in dentistry for two decades and I had never read one. Nobody ever told me they existed. So when I did read one, and then I read another, and what I found is in there was not opinion. It was a regulator with a warrant in this case, describing exactly the thing that we've all been feeling and chatting about in the Facebook groups, talking about how insurance companies and you know they're unfair and XYZ, and we share all these templates in order to fight back. And really what we're doing, friends, is just falling for what they designed us, designed for us in the first place. And friends, I got obsessed with reading these things. So I'm gonna tell you something about myself, and I don't want you to judge me for it. It kind of became a hobby. Like, you know how other people watch shows? I have a folder, 52-page PDFs from state insurance departments, consent orders, enforcement actions, market conduct reports, and I read them the way other people read a thriller because that's kind of what they are. Somebody with legal authority walking into an insurance company, reading their files, and wrote down what they found, and then the state published it. And almost nobody in our industry is reading this stuff. So I want to share the findings with you because it's interesting when you read up on this, and it's across medical and dental, but it's insurance, healthcare insurance patterns, and the abuse is real. What you're feeling, the unfairness, the unreasonable denials, the burying us in unnecessary paperwork. It's real. And insurance companies are getting cited for this stuff all the time. And we're still playing an old game. The insurance company has shifted the way they play the game, and we're still using templates. Like let that sink in for a second. We are falling for it almost 100% of the time. And you know how I know this? Because I'm in all the Facebook groups and I read all the comments and see all the conversations and all of the really bad information that is passed around in there by aka gurus. You know, it's just so sad to see that we have just not evolved as an industry. So I'm hoping that this episode empowers you to create change in the healthcare insurance arena. And this is the part I want you to take from me today, even if you take nothing else. Friends, hear me loud and clear on this. A fine is a confession. When a state finds an insurance company, the state is telling you in writing exactly which behavior could not survive the audit. That is a map of where their weak spots are. And that's exactly what I want you to pull from this episode. So if you know what they are getting fined for, you can work backwards. You can reverse engineer the whole denial. Think about what that means. Every fine is a behavior an insurance company

Why A Fine Is A Confession

SPEAKER_00 9:10

could not defend, which means every fine is a question you are allowed to ask. Every fine is a document you are allowed to demand, but they won't tell you that. A deadline that you can hold them to because you finally understand how to hold them to these deadlines. With this information, you're gonna be able to ask the exact questions that a state has already forced an insurance company to answer. And you ask them in writing. I want you to be able to look at a denial and see right through it, like in the words of Mariah Carey, like it was bathing in Windex. You're gonna look at a denial letter or an additional information request, and you're gonna see the whole machine standing behind it, the one that was designed to delay the payment. So we're gonna go over three elements that I teach in the workshop. And we're gonna start with element one. And I'm starting here because it's the piece that nobody taught any of us. You have heard the phrase clean claim, and we've all heard it like 10,000 times. It's almost like a buzzword in our billing industry right now. Submit clean claims, improve your clean claim rate, clean claim percentage. It just gets thrown around at every seminar in this industry, like it means to be careful and do good work. I need you to know that that is not what clean claim means. It's not even close. Clean claim is actually a legal term, it comes out of prompt payment law and it exists in federal

Clean Claims And The Prompt Pay Clock

SPEAKER_00 10:55

statute for exactly one reason. It defines when the insurance company's payment deadline starts and when they start owing your practice interest. That is it, and that is the whole job of that phrase. It is not a compliment, it's not like a quality score. It's actually a switch that gets turned on. And when a carrier tells you that your claim is not clean, they are not critiquing your work. They're stopping the clock. So now that you understand that concept, a clean claim is defined as a claim without defect and improprieties. And it gives the insurance company a green light to deny or pay. However, the insurance company also knows that if they request additional information, that prompt payment timeframe that they have, which is a federal law, usually 30 days, depending on the state, that prompt pay time frame comes to a stop. The additional information request is a decoy disguising your claim to have defect or impropriety. When in fact you have submitted a clean claim with sufficient evidence, proving dental and or medical necessity, they have everything they need to pay the claim. They are just playing a game with you that you fall for every single time, right? So when you know how to package a clean claim from a legal standpoint, right? There is a legal architecture that we need to understand behind each claim that we submit, because whether you want to believe it or not, you are part of a bigger legal system. And when we submit sloppy claims, claim slop, we are playing into the game that the insurance companies are playing with fire. And we have water guns. So when you understand how to recognize, now we're gonna go back to Bathing in Windex because when you're looking at an additional information request, you know you have submitted a clean claim. Remember, that is a legal term and it lives within the prompt payment law, which is a federal law. You are gonna call the insurance companies bluff. And you are going to do so because you know the game they are trying to play. In the Medicare statute, Congress did not see, Congress did not set one payment deadline. They set up a countdown. Claims received starting October 1, 1986, 30 days, that they got a 30-day window. Starting October 1st, 1987, it went down to 26 days, 1988, 25 days, 1989, 24 days, every year got shorter. From the very first day that this idea entered federal law, the direction it was moving was faster payment, no more additional documentation required. We Congress was trying to force faster payment, and it kept squeezing the deadline down. So somewhere in between 1986 and today, a concept that was built to make insurance companies pay us faster got turned into a stick that they beat us with. And we let that happen, partly because nobody ever told us where that term clean claim came from. There is more than one federal definition, and they are built backwards from each other. And I'm gonna do my best to explain this. Medicare defines a clean claim as one with no defect or impropriety. And then it says in parentheses, including any lack of required substantiating documentation. Required. Documentation only makes your claim unclean if it was required. So the real question is not did you send enough? The real question is required by who? If that requirement was never published and never filed with the state and never handed to you as a participating provider, then your claim was clean the day you sent it in and the clock has been running the entire time. Now, here is the Medicaid definition, and this one made me angry for about a week. A clean claim under the Medicaid regulation means one that can be processed without obtaining additional information from the provider or from a third party, without obtaining additional information, which means under that definition, the request is the thing, not the missing x ray, not the missing narrative. A payer who asks you a question has, by the planned terms of that definition, just moved your claim out of clean status and stop their own clock. And there's one more line in that regulation. It says a clean claim does not include a claim under review for medical necessities. So flag it for review and it leaves the prompt payment world completely. Now there's no deadline, no interest owed to you. Did you even know that? Have you obtained prompt pay interest for older claims that you get paid? We just had one that we got paid from 2024. And you better believe we also got prompt pay interest paid to our client as well. Now put that next to what the Rhode Island examiners found. They found that Delta Dental of Rhode Island requested documentation, and I'm quoting on a sequential basis. Ask for one thing, then ask for another, and then another. Under a definition like that, it is the single most efficient way to keep a clock from ever starting. When you see denials, unreasonable denials, and unreasonable additional information requests, and going back to what I just quoted, sequential requests. Okay, they're asking for additional documentation on a sequential basis. That is straight out of the examiner's findings. They're doing it on purpose. And when we play into the additional information request by calling the insurance company to find out what they need, right? Rather than packaging a very, very strong claim, a clean claim by legal definition, one with no defects or improprieties, we are playing a better game because we are not going to play into that. We are not going to allow them to stop the clock. We are going to call them up and let them know we have sent you everything. And be sure that you have proof of all of that. Because when they want to claim that they never received anything and you have a receipt, you do not let them stop the clock. That additional information request, assuming you sent in a clean claim, you provided sufficient evidence proving dental necessity. Assuming all of that, we are not going to play into that additional information request. We're going to play the game differently and we're going to let them know that we sent in everything they need to pay the claim. The benefits are available to the patient and they need to pay the claim, or we are going to report this to whatever governing agency. It's not always the insurance commissioner. I use the term insurance commissioner because it's one that is digestible, but that's really where the training starts. The reality is you have to know which regulatory agency is the governing body for that particular plan, because self-funded plans are not going to be heard by the insurance commissioner. Those complaints are not going to be heard, but they will be heard by the Department of Labor. And in my workshop, we talk about the different agencies, how to know which agency to file your complaint to. It's important. But first, step one is you have to know the laws that apply the legal architecture behind this billing game that we play every single day as dental billers. And when you understand that, you look at denials differently. You look at these additional information requests with authority. You know, like it, I can see right through you. And we play the game with fire. So now we're fighting fire with fire, not with some water gun template that was passed around in Facebook because somebody in there said she's been using it for 10 years and it's worked for her every single time. Well, guess what? AI is changing all of that. So hopefully you are not using a template. And we talk about that in the workshop as well. So that is element number one is to think like an examiner. Use those findings in the market conduct examinations and use this information in your interactions with the insurance company. And I want to give you the sentence that I think is the most valuable sentence in this entire workshop. Rhode Island's regulation requires a carrier to have a written complete claim standard and hand it to participating providers. And when the examiners looked at the carrier's standard of what their definition is for a complete claim, they found that it was way vague. They wrote that the provider couldn't know what information the carrier needs in order to adjudicate a claim. And then they added this. Implicit in this standard is the requirement that the claim the clean claims standard be reasonably constructed so that it can be understood by the average provider. A state regulator held that a standard the average provider cannot understand does not satisfy the regulation. Vagueness is not a gray area to a state regulator. Vagueness is a violation. And they ordered the insurance carrier to go make it more specific and file the new version. That is element number one, friends. The definition is the fight, how we fight. So let's go into element two. Element two in this part this is the part that people in the room get the most excited about because you can use this tomorrow. There are two questions. That's it. And they're not clever. I didn't design them to be clever. And they're also not aggressive because we don't need to be aggressive with the reps at the insurance companies. I mean, they're just doing their jobs. Here's question one. What filed policy provision supports this denial? Can you please identify it? I'm gonna say that again. What filed policy provision supports this denial? Please identify it. Here's question number two. Which licensed dentist

Two Questions To Use Tomorrow

SPEAKER_00 23:16

reviewed this claim? What is their license number? And did they review the documentation that was submitted? Now, why those two questions? Because in December of 2024, the Washington State Office of the Insurance Commissioner fined Delta Dental of Washington and its benefit manager $150,000. And one of the reasons in the state's own announcement was denying claims based on terms that had never been filed and approved by the insurance commissioner. Never filed, never approved, and they denied on these standards, anyways. Then in October of 2025, the California Department of Managed Care fined Cigna $100,000 on two findings. The first one is that they denied provider claims as not medically necessary without physicians conducting clinical reviews before the denials went out. Now that's medical. The second one is that Cigna used a different review process than the policy had filed with the department. So we've got one dental example and one medical. Two different states, two different regulators, and it's the same legal theory in both. The insurance companies adjudicated the claims under rules it never showed anybody. And when you learn about these things, you play the game differently, right? So now you're learning that some of your denials, though they might be legit because some people do submit sloppy claims, but for the most part, we do try our best to submit a clean claim with sufficient evidence proving dental necessity. And you still receive a denial. I want you to understand that anybody that tells you they can guarantee that, you know, you're all of your claims are going to get paid within 30 days, they're lying to you. You cannot control the insurance company's behavior. You cannot control the fact that they're denying claims with standards that they never told anybody about. That's illegal, but they're doing it and we don't know that they're doing it, so we don't know what to look for. Well, now you know. Now you are gonna go back to that question number one, and you're gonna hold them accountable because every single denial needs to be tied to a policy provision that supports the denial. What filed policy provision supports this denial? Please show it to me, identify it, and send me a copy. Because if they can't give you the policy provision that supports the denial, then that might be a violation of law. It must be filed with the insurance commissioner. And I want you to ask in writing every single time. So yes, you can call up and speak to a rep, but when they do not answer, you're gonna write that down because a non-answer is evidence and you are going to need it for element number three. So let's get into element number three. And this is the piece that changes what you actually have. One denial can be considered a service issue. 200 denials with a rate attached is a general business practice. Okay. This is something I have done for many, many years. I am obsessed with pattern recognition. I like to identify different patterns and keep track of them. And I'm just a geek that way. When you have one insurance company that in your gut you know is bullying you with drowning you in paperwork and all these additional information, they are bundling codes together

Turn Denials Into A Pattern Case

SPEAKER_00 27:29

for payment. Those are all forms of abuse. And we need to track and document all of that. How do you recognize? How do you confidently report to the insurance commissioner a general business practice being imposed on your practice? In most states, the Unfair Claims Settlement Practices Act says that an insurance company violates the law when the conduct happens with such frequency as to indicate a general business practice. That phrase is a trigger, my friend. It is written into statute, which means regulators do not act on unfairness. They act on frequency. So the whole afternoon of the workshop is about turning what happened to you into a number. Your first pass denial rate, payer by payer and by code, because insurance companies have built in first pass denials for certain codes. They have been fined for doing so. Your appeal overturn rate, how many days from a clean claim to payment, and the one almost nobody tracks, which is your own appeal rate. Because if you're only appealing a handful of your denials, then the mechanism I described at the beginning of this episode is working exactly as designed. And we are a part of the reason. Then I want you to take the number to the right forum. And I have to say something about that because getting this wrong is the most expensive mistake in this whole process. Your plan type decides your regulator. Fully insured commercial goes to State Department of Insurance. Medicaid Managed Dental goes to State Medicaid Agency and the Attorney General. Medicare Advantage goes to CMS and self-funded plans, the ones where the employer is paying the claim and the carrier is just administering the funds, those largely go to the United States Department of Labor because ERISA limits what a state commissioner can reach in that case. So the last one can be a bit of a trap for some people because if you file a complaint on a self-funded plan with your state insurance department, it'll bounce. And this is where I've seen that happen in the past. And people that have attended the workshop have stated that they have filed a complaint with the insurance commissioner and nothing happened. Well, that was the bounce. That was because the insurance commissioner has no authority over a self-funded plan. And you went to the wrong agency to report and file the complaint. So in our workshop, we spend a good amount of time going over different plan types and where to submit those complaints to so that you don't waste your time and energy in trying to file a complaint and it's just never heard. And that's where I hear a lot of well, I did try once doing the using the power of the insurance commissioner and nothing happened. So we don't do that. I can tell you 100% of the time, that's probably because you filed it with the wrong agency. Okay, so people that attend my workshop and want to learn this stuff know that one claim can change the game. I know a lot of people are thinking this is just too much energy, too much work to file a complaint with the insurance company. With, I'm sorry, with the insurance commissioner or the proper regulatory agency. Even if you do all this, the insurance company gets a slap on the wrist and nothing happens, nothing really changes. Here is the Rhode Island number. The regulator fined that carrier zero dollars. So I don't remember if it was Delta Dental of Rhode Island. I could be wrong, but we'll use that as the example. But in any case, it was a dental insurance company and they got fined nothing because the fine is not always the goal. And they got 19 mandated corrections, each one mapped to a specific audit procedure that the department would use to verify it. The carrier had to start accepting verbal appeals instead of demanding everything in writing. It had to record and act on all complaints, oral and written, not just the ones you had to file on paper. It had to publish a specific complete claim standard by procedure. It had to stop using utilization review as its way of policying quality of care. It had to give a provider advanced notice and access to the audit before putting the provider on full review. It had to rewrite its denial language so it actually told you what would make the claim payable. It had to study why its own denials were getting overturned. Zero dollars friends, but 19 obligations. That is the lesson I want you to take, even if you never take my workshop. Fines do not change insurance companies or insurance carriers. Fines are just a line item in the audit. What changes carriers' obligations is monitoring audits, having to file something with the state and prove they did it. So when you decide to escalate, escalate towards the insurance company's obligation to change. Okay, look at who those 19 corrections applied to. They did not apply to the 23 people who filed complaints. Those corrections applied to how that carrier had to behave with every single provider it dealt with. All of them got a carrier that now has to accept verbal appeals. All of them got a carrier that now has to public specific claim standards by procedure. So, yes, learning this should change how the insurance company treats your office because now you have an idea of how to fight fire with fire. This is just a small version of what you are doing. The big version is that you are going to start changing insurance behavior. That is advocacy, my friends. And that is the real difference. So now that we have gone through the three elements, I hope that that has inspired you to change the way you respond to additional information. You are not just the biller, you are a patient advocate. I will see you in the next episode, friends.