27,837 Denials. Zero Appeals, make this make sense!

Delta Dental’s logo is everywhere in dentistry, but the numbers most practices never see are sitting in plain sight in a federal CMS dataset. We walk through the CMS Transparency in Coverage Public Use File and focus on the rarely opened tab for individual marketplace standalone dental plans. Because carriers self report claims received, denials, resubmissions, and formal appeals, the file becomes an uncomfortable mirror for both payers and the dental billing systems we run inside our offices. 

Here’s what stops us: Delta Dental companies across 20 states report a 22.5% in network denial rate, higher than the broader dental market in the same file, and out of network denial rates climb even further. But the real gut punch is what CMS added for 2024: resubmitted claims. When only a small fraction of denied claims come back through the door, it suggests a huge pool of abandoned revenue sitting on aging reports, quietly turning into write offs and patient balances without a deliberate decision. 

We also get precise about formal appeals: what counts, why plan documents matter, how deadlines create leverage, and why regulators only have visibility when we generate a paper trail. Then we turn it into action with a practical denial management process, simple tracking fields your team can start this week, and a challenge for practice owners to stop accepting “I need to appeal those” as the end of the conversation. Subscribe, share this with your billing team, and leave a review with one change you are making after you pull your last 90 days of Delta denials.

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Transcript

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Why This Data Source Matters

SPEAKER_00 0:22

Before we get started, I want to tell you exactly where I got the information about today's episode. I promise you, at the end of this episode, you're gonna want to go check this information for yourself. And I think that you should. So the information for today's episode did not derive from a survey. It didn't come from a statistic that somebody read off of a slide at a conference. Today's episode derives from a federal file. The Center for Medicare and Medicaid Services publishes something called the Transparency in Coverage Public Use File. It exists because of a section of the Affordable Care Act that says if you're going to sell insurance on a marketplace, you have to tell the public how many claims you received, how many you denied, and how many people appealed. Every insurance carrier has to report it. And this is the part I want you to remember. The insurance companies are reporting this information themselves. This is not coming as a result of audit findings. It's not as a result of an investigation. The insurance company is simply filling in the boxes and sending it into the federal government, and the federal government publishes it exactly as it is submitted. So everything I'm going to tell you is based on this report. I downloaded that file, the 2024 numbers published last September 2025. It opens as a spreadsheet with four tabs. Most people who look at this file go to the medical tab. There's a whole industry of analysts who write about the medical tab. There are foundations that publish annual reports on the medical tab. There is a third tab, and it's labeled Individual Marketplace Standalone Dental Plans. As best as I can tell, almost nobody ever opens this file. So you know your girl had to open it. 652 rows, 64 dental carriers, and sitting right smack in the middle of it, 14 separate Delta Dental companies operating across 20

The Overlooked Dental Marketplace Tab

SPEAKER_00 3:04

states. This file covers individual marketplace dental plans only. People who bought a dental plan on their own through the exchange. It's not including group plans or employer coverage that most of our patients walk in with. It also does not include California because California runs its own marketplace and does not report to this file. The claims here are counted at the service line level, and the denials include everything: duplicates, eligibility, timely filing, all of it. So this is not your entire world. This is just a window into a piece of it. But here is why that window matters. It is about a million claims with the same dental insurance companies, the same claim systems, and the same policies. What you are about to hear is a core sample, and you can tell a great deal about a huge mountain from just a sample. Okay, here is what they reported about themselves. Across those 20 states, the Delta Dental Companies received 932,795 in-network claims in 2024. They denied 210,297 of them. That is a 22.5% denial rate. More than one in five. Now, I want you to hold on to that number because on its own, a number does not mean anything. 22 is only high or low compared to something. So I ran every other dental carrier in that same file. All 63 of them: DentiQuest,

Delta Dental Denial Rates Versus Market

SPEAKER_00 5:17

Guardian, Cygna, United Healthcare, all the blues, and 123 million claims. Let that sink in. 123 million claims. The rest of the dental market denied at 17.7%. Okay. Delta Dental denies in-network claims at a much higher rate. I would even say a meaningfully higher rate than the market it dominates. I'm gonna repeat that so that you guys can hear that loud and clear. Delta Dental denies in-network claims at a much higher rate than the market it dominates. The largest dental carrier in America, the one whose logo is on the wall of half of the dental practices in this country. And the one your patients trust the most, because the name is so familiar, denies more than the competition by their own reporting. And out of network, it gets worse. Out of network, they received 83,521 claims and denied 29,095 claims. That's nearly 35, more than one in three claims were denied when they were out of network. Now, I'm gonna give you the number that changed all of this from an interesting afternoon into an episode I had to record. Starting with the plan year 2024, for the very first time, CMS required carriers to report something new, resubmitted claims. How many previously denied claims came back through the door, corrected and resubmitted? Think about what this field actually measures. This is our work. It's measuring us, the biller at the front desk pulling the EOB, finding the error, fixing the narrative, attaching the X-ray, and sending it back. That number is a measurement of whether the dental billing profession showed up. Delta Dental denied 210,297 in-network claims in 2024. 31,418 were resubmitted, 15.2%, which means roughly 85% of denied claims were never sent back. Not once. Denied and then nothing. No correction, no resubmission, no appeal. They were denied and then they died at that stage, and they were left on the insurance aging report. Now, with all of that information,

Resubmissions Reveal Abandoned Claims

SPEAKER_00 8:26

you know, this is a lot. Let me put that next to something else. Experian Health runs a survey every year called The State of Claims. Last year's edition asked revenue cycle leaders about their denial workflow. 90% said they rework. I want you to keep that number in mind. The federal data from the CMS report says 15%. I want to be careful and I want to be fair here because those are two different measurements, but the gap is not five points. It's not even 10 points. It's 75 points. The gap is 75 points. Somebody is telling a story that the file does not support. I told you the file also supports appeals, formal appeals. And I want to be precise about what that field is, because precision is how you keep your credibility. The appeals in this file are the formal appeals of an adverse benefit determination of a denial. The ones the plan documents describe. So hopefully you guys all understand what a plan document is. If you don't, a plan document is what HR has. It's kind of like a breakdown of benefits, but on steroids. And a plan document describes exactly what your patient's plan covers and then some. So when you have a denial, instead of going straight for an appeal, it's best if you can get a copy of the plan benefit document, because if it is a covered benefit, it will be outlined in the plan benefit document. And you can just reach out to the insurance company, let them know that based on the planned benefit document, that this is a covered benefit, the patient is eligible. So they need to process. We don't need to tell them that we're going to report this to the insurance commissioner, at least not yet, right? So when you appeal, when you do a formal appeal because there is something that the insurance company denied, and there's no merit attached to that denial. It's just like one of those denials that makes you scratch your head. That's the type of appeal that we're talking about. These appeals have deadlines, right? You have a certain amount of time to appeal what is called an adverse benefit determination, or as I refer to it, an unreasonable denial. Timelines, and there's required response times and a paper trail that a regulator can subpoena. This is escalation and it's the step past a resubmission. It's the moment somebody stops asking nicely and starts invoking the contract. Across the Delta Dental Rows, there were 203 formal appeals against 102,000 denied claims. That is about two appeals for every thousand denials. Two-tenths of one percent. If you listen to my last episode, I did some research based on my own internal numbers. It wasn't like a national survey or anything. It was just for my own company. And when we onboard a new client, we also document their denial management process. And less than 1% of all denials prior to coming on board with Fortune were ever appealed. And the number one reason that came up is just not enough time in a day. And I totally understand that. I'm with you on that. But you guys, two appeals for every thousand denials, two-tenths of one percent. So my own survey said less than one percent of all denials were ever appealed. And this is a federal file that is reporting that two-tenths of one percent of all the denials Delta received in 2024, and I'm talking about 20 states were ever appealed. But here's the thing: that's not even the

What A Formal Appeal Really Is

SPEAKER_00 12:57

part that got me. Six of those companies reported a number, and the number they reported was zero. Friends, Delta Dental of North Carolina denied 27,837 claims. Formal appeals filed, a big fat zero. Delta Dental's Plan of Ohio, 9,674 denials, zero appeals. Nebraska, zero. Indiana, zero. Arkansas, zero. The North Dakota book? Zero. They typed zero in that box when they were filling in the information to submit to this federal file. This is the insurance company themselves reporting their own information. This is not, again, this is not from an audit. What stopped me cold in my steps, if that's how the saying goes, two years ago, I came across Delta Dental of Virginia's own transparency page, the one that they are required to post on their website. It's been sitting there unchanged for years. And it says 57,692 claims. Out of 57,692 claims, 11,844 were denied. Total number of appeals, zero. And I honestly thought that was a fluke. I was like, somebody forgot to update that number. It wasn't. It was a pattern. It wasn't a fluke. So I sat with that and I was a little angry. I had the whole episode written in my head, like who the villain is, and this big denial rate. Everybody nods along and shares this information, and nothing changes. The thing about that 85%, Delta didn't fail to resubmit those claims. We did. Delta denied them. That's what they do. That's the business model. And I'm not gonna act shock, but 178,000 denied claims sat there. And nobody in a dental office or third-party billing company for that matter picked them up and sent them back and appealed them. Nobody wrote a single appeal for any of those denied claims, not a single escalation. Those zero appeals, that's not a delta failure. A zero in the appeals column means that not one single office fought back. Not one in a state for one whole year. Here's the thing, you guys. I have been teaching in this industry for 25 years. I have stood in 31 states and in Mexico and told rooms full of billers that they're not just the biller and that you are a patient advocate, that the appeal is the most powerful tool they own. And I am looking at a federal file that says the appeal is barely being used. This is not a Delta problem. This is our problem. And I would much rather tell you the truth about us than let you leave here comfortable. I want to be careful because there is an easy conclusion here, and I believe it's wrong. The easy conclusion is that billers don't have enough time in a day. That is not it. Time is not the problem. The problem is that nobody is checking. Accountability is the problem. Let me describe a conversation that happens in a dental office every single week in this country. The doctor is looking at the aging report. There's a bucket over 90 days that keeps

Zero Appeals And The Accountability Gap

SPEAKER_00 17:14

growing. The doctor points at it and says, What's going on? And the biller says, those are denials that I need to appeal. And the doctor says, Okay. And that's the end of the conversation. That's it. That's the whole control system. I need to appeal them. Those are denials that I need to appeal. Nobody asked when or how. Is there any documentation that needs to go along with it that I can help with? Is there an appeal deadline that we need to be aware of? And I want to say this as kindly and clearly as I know how, because I absolutely love this profession. And I'm not here to accuse anybody of anything. It is not that your biller is lying. It is that nobody has built a system where the truth is visible either way. When there is no system, I need to appeal it, means I need to find the time to appeal it. And an aging report isn't gonna tell you anything beyond the number that's attached to it. And if you don't know how to interpret an aging report and you don't look at it on a regular basis, you're not gonna see the patterns. Take a practice doing $2 million a year in production. Maybe a quarter of that is Delta. Delta is the number one payer. When you look at a practices insurance mix, I used to think that you could, you would have like your top 10 insurance payers. And what I found through all of the billing department audits that I've done, it's usually your top five that make up most of the insurance income to the practice. So if you pull your top five almost 100% across the board, it's been very rare where I don't see that Delta is the number one insurance payer and they dominate your insurance income. So say a quarter of that 2 million in production is Delta. That is $500,000 flowing through one insurance carrier. And sometimes I've seen it much higher. At their own reported 22.5% in network denial rate, that is roughly $112,000 in claims denied over the course of a year. Now I want you to apply the resubmission number. 15% get reworked, which means about $95,000 in denied claims never got touched again. Friends, I refer to this as abandoned revenue. This is revenue that if we were to appeal, every single denial that comes through our doors, every single, we're not gonna pay for that, every single, we're gonna bundle those two procedures together. If we were to appeal, we could have some change. But when insurance companies are reporting as required to the federal report, and they're reporting that nobody's appealing, they are laughing all the way to the bank. I know what some of you are thinking at this point because I've heard it in every workshop I've ever taught. A lot of those denials were legit denials due to frequency missing tooth clause annual max. And you're right, some of them were, but tell me which ones. Show me the report that separates the denials you correctly wrote off from the denials you just gave up on. You do not have that report. Nobody tracks this information. And this is exactly why insurance companies are winning, because we're not treating our billing department like a business within a business, and we're also not acting as patient advocates. We're acting like we just have a job, a good old J-O-B. And if that's the way you view billing, if you think of it as a job and not a profession, I'm gonna ask you to leave because we are professionals and we are also patient advocates. And that is the problem. We are not treating our position as an advocacy for our patients. And the insurance companies are gonna continue to win until, as an industry, we level up. So, with all of this information, here is what I want you to do. I want you to be really practical because outrage that does not turn into a process. Friends, we're just entertaining. The insurance companies. And I didn't come here to entertain them. You need a denial management process, and you need to have it written down. It cannot live in somebody's head because, as clearly described in this federal report, insurance companies are telling on us now. Now that report is showing the true numbers and the true resubmission rate and the true appeal

Build A Real Denial Management Process

SPEAKER_00 22:53

rate. And when 20 states report zero appeals in a one-year period, I can't defend us. You guys know how hard I advocate for us. But when as an industry we just get that denial and we don't push back and we just pass that on to the patient, that's not advocacy, friends. That's laziness at its finest. Every denial needs to get logged the day it arrives. A denial that is not written down is one that does not exist and will not get worked. We need to have a running spreadsheet of keeping track of denial patterns because once you start doing this and you start documenting denial patterns from which insurance companies, which codes typically get bundled. I can tell you unequivocally, right now, we are dealing with a lot of guardian issues, and we are reporting those issues to the insurance commissioner or the Department of Labor, depending on the plan type, but we are logging it to track those patterns. Things like the date the denial was received, the carrier, the procedure, the dollar amount, denial reason, exactly as it appears on the EOB, not paraphrased, and the appeal deadline. This is the part that nobody does. I don't think a lot of billers know to do it, but now you know. It's like one of those things where you can't unhear this, you can't unsee it once you see it. So I hope that you feel the weight of my message today, because reading this report truly sunk my heart because I thought we were doing better as an industry. And if you happen to be the unicorn, and after seeing this report, I will say the billers who actually appeal, those are our patient advocates, those are our unicorns. And I just want to say thank you. Thank you for staying on top of your profession and appealing benefits that your patients are entitled to. Before you decide to write off any of these denials or adjust the balance off, that has to mean that a decision by somebody is being made on purpose, not something that happens because 11 weeks went by. Before anything is written off over a certain dollar amount, there should be a second signature next to that because this is where we start to enter the world of adjustment slop. And I did a whole episode on that. An appeal is not an appeal because somebody says they appealed. An appeal is an appeal because there is a document, there is a letter, there is a date it went out, a method it went out by, there's a confirmation number, and the response when it comes in is receipt of that appeal. If there is no artifact, there was no appeal. Not because I think your team is dishonest, but because a process that cannot be verified is not a process, right? So again, going back to denial management, we need to have systems in place so that processes can be documented and a documented process can now carry a level of accountability. And we can actually start to transform as an industry. And when I look at next year's report, I would love to see that as an industry, we appealed a lot more in 2025 and then more in 2026. So I'm still waiting for 2025 numbers to come out. I believe it'll be this September next month. It's August 11th today of 2026. So probably in a month, I will do another episode on how we did in 2025. And I'm hoping that those numbers look a lot better. This next part is for my doctors. If you're listening to this, this is for you. As the owner, as the doctor, you do not need to understand dental billing to run your reports. The appeal column is at zero, two months in a row. Ask why. And this is assuming that you start tracking your denials. We track all denials because we appeal them. And then we monitor our approval rate from our appeals. I believe we were speaking to one of our busiest practices this morning, and we are at a 94% approval rate on the appeals that we are submitting. And here's another thing I want doctors to hear Denials are not a reflection of your biller performance. Denials are issued unreasonably. And as I mentioned earlier in this episode, Delta Dental, how do I put this, denies much higher than the other insurance companies combined, right? So Delta Dental is out denying the market that they dominate. So how could that ever be a reflection of your biller's performance? It can't. You cannot control how often an insurance company denies a claim. There is something called a first pass

What Practice Owners Should Track

SPEAKER_00 29:09

denial. And insurance companies will say that they are extremely conservative, and that's why they have a higher denial rate than others. They will use broken adjudication systems, and they will use the excuse that, you know, they're just conservative. That is not the case. This is a business model. Denials are a business model because insurance companies also know that less than 1% of denials gets appealed. So why would they not use this business model? Now, I also want to say a caveat to that. There's also a lot of sloppy billers out there. Billers who, again, as I mentioned earlier, they have a J-O-B. They do not have a career, much less look at this as a profession. So yeah, there's sloppy billing out there, but it doesn't always mean that you have a bad biller. There are bad billers, don't get me wrong. There are billers that will submit a claim without clinical documentation to back it up. There are billers who are padding your claims and you don't know. There are billers who are adjusting off collectible money because they just don't get paid enough. There's a lot of things that are going on that when you don't track, the problem gets bigger. Okay, I want to come back to those zeros one more time before we close out this episode. There is a second layer to them. You guys know how I feel about all of this. I'm all about law before codes. Every one of those denials sits inside of a contract. Every state has an insurance commissioner, every carrier has prompt pay statutes that they are subject to and a claims handling standard that they are legally required to meet. And in six states across an entire year, the number of times anybody formally invoked any of that against Delta Dental was zero. Insurance companies are not afraid of your phone call. They have people whose entire job is to handle your phone call. A formal appeal with a deadline attached or a complaint filed to the Department of Insurance that requires a written response within a statutory time frame, that's what they're afraid of, friends. I've talked on this podcast before about the Rhode Island market

Regulators Only Move On Complaints

SPEAKER_00 32:03

conduct examination, where a regulator went into Delta Dentals claims files and looked. And regulators do not go looking on their own. They go looking when complaints start to stack up. But if we're not even filing an appeal, because you do have to give the insurance company an opportunity to undo that unreasonable denial. But if we're not even taking that first step, how can we ever imagine that we would be utilizing the power of the insurance commissioner? And again, this is what I call abandoned revenue. Those zeros, friends, those are not just lost revenue. Those zeros are the reason nobody is looking. Every appeal you do not file is a data point. And it's a data point a regulator never sees because you're not filing an appeal. I want to tell you about one row in the spreadsheet because it's the most honest thing in this entire file. Delta Dental Insurance Company's Florida operation reported that 1,203 formal appeals were filed in 2024. And it reported that 16,518 of those appeals were overturned. 16,000 overturned out of 1,200 filed. That's a 1,373% overturn rate, which is not a high number. It's an impossible number. You cannot overturn more appeals than were filed. It's like reporting that you sold 12 cars and refunded 160 of them. That number is in a federal file submitted by Delta Dental, published by the government, and it's been sitting there since September, and nobody caught it. Nobody sent it back. The reason I'm talking about that is because of what it proves. It proves that there is no precision in these organizations. It proves that some denials are given for no good reason. They're issuing denials at scale and they're counting on us not to look. This week, you don't need to overhaul everything based on what you learned in this episode. But what I would like you to do is pull your Delta denials from the last 90 days, just Delta. Not because I'm singling out Delta, but because I've done enough billing department audits to know that I can almost bet my house on the fact that Delta is your number one payer. I want you to count them, and then I want you to count how many you appealed. Whatever that number is, even if it's zero, it's your starting point. And if it is zero, you are in very

Your 90 Day Denial And Appeal Challenge

SPEAKER_00 35:28

large company, friend. I believe that our work matters, and I believe you were put in that chair for a reason. And that stewardship of what you have been given is not a small calling just because it happens on a spreadsheet. Go build the process and get your patient's benefits paid. I'll see you in next week's episode.