066: Part 3 Dental Insurance

In the final episode of the 'No Silver Spoons' insurance education series, host Sarah Beth Herman discusses the challenges and solutions for navigating dental insurance in 2025. The unpredictable year has seen subtle policy changes, shifting reimbursement models, and increased claim complexity. Sarah emphasizes the importance of thorough verification, smart claim submissions, and structured follow-ups to avoid costly mistakes. She provides actionable advice on building a robust verification system, educating patients, and streamlining the billing process. The episode also covers the importance of understanding non-standard policy clauses and offers tips for effective patient communication. Leaders are encouraged to build scalable systems and ensure their team is well-trained. Sarah's guidance aims to empower dental professionals to handle insurance confidently and achieve smoother operations.

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Chapters

• 2:02 Why 2025 Is So Tricky for Insurance Teams
• 3:41 Not What You Know – But What’s Evolved
• 5:41 Verification Workflows That Actually Work
• 10:47 Follow-Up That Doesn’t Fail: The 10-20-30 Rule
• 14:58 Mastering Insurance Conversations with Patients
• 16:15 Leadership That Scales Your Systems

Transcript

  📍 Welcome back to No Silver Spoons. I'm your host, Sarah Beth Herman, and this is part three, the final episode of our insurance education series. If you've made it this far, you are the kind of dental professional who wants to lead with confidence, accuracy, and impact, and I am so proud of you for showing up.

I was not born with a silver spoon, and I don't know that you were either, but maybe you were. And life is just really, really easy for you. But I have learned that it's not that easy, and I have loved every single person that has poured into me and taken the time to give me tips and tricks and helpful things that have made me better.

And so that's what this episode is for you. This episode is your final section of your full playbook for mastering dental insurance in 2025. Let me share with you why I'm even talking about this and why this episode matters even more now that you have made it to the final chapter of this three part series.

 Even the most seasoned insurance verifiers and dental billers have found 2025 to be one of the most unpredictable years in recent dental insurance trends.

And you might be asking, well, why? What do you mean I haven't heard any of this?  Well, that's because policy changes are subtle and platform navigation is changing on every single site. And reimbursement models are shifting behind the scenes

According to the American Dental Association's 2025 overview of insurance trends. Over 60% of dental offices report increased claim complexity. I. Not because of new codes, but because policies themselves are being reworded, redirected, and buried under third party administrators.

So here's something that the A GD published this spring. While the number of Americans with dental coverage is higher than ever out of pockett, expenses for patients have increased by nearly 13% compared to 2023. Often because offices failed to verify new plan exclusions or missed subtle downgrades.

This isn't a beginner's issue. These are advanced level verifications that even experienced team members struggle with if they don't have a system, and that's why I'm here. I want to give you the tools that don't just make your job easier, but they help your office get paid what it deserves to get paid, and your patients feel confident in your expertise.

This episode is different because it's not about the reminders that you've heard. It's about what isn't being talked about. Even among veteran billers, and here's the truth, seasoned verifiers can still fall into autopilot. They assume a payer still works like it did last year. But plans change and they don't always tell you.

In fact, according to a recent A DA bulletin, more insurance providers are hiding fee schedule changes behind some obscure admin login portal, which means if your team isn't logging in regularly or calling your missing real time updates that impact your collections.

Another fact I read was a, the A GD reported in quarter two of 2025 that claim re rejection rates have risen by 11%. This is largely due to outdated player platform use and staff not being trained in nuances of newer managed care models.

So this episode isn't about did you verify coverage? It's about do you know if the patient's plan changed networks this quarter? Do you know how this PPO applies alternate benefit rules in non-traditional ways?  Has your team seen the new 2025 CDT code language updates for periodontal reevaluation? These are the layers I'm here to unpack. Not what's common, but what's evolved. In episode one, we talked about CDT code updates, umbrella plans, and claim rhythms.  Episode two dove deeper into frequency limits coordination of benefit rules and what bottlenecks are holding your claims hostage. And now it's time to tie it all together with strategy systems and solutions that can actually implement.

This episode is a little bit longer, but I want you to grab a notebook, open up your Google Drive, or forward this episode to your team. We are covering real billing workflows, insurance follow up systems, patient education and what it takes to create a dental front office that is truly unstoppable.

So let's start by talking about why verification workflows deserve so much attention. I know some of you might be thinking, we already verify insurance. We've got this down. But the truth is, even high performing teams are missing important elements and 2025 insurance companies are changing how they present data.

Some carriers are now segmenting benefits by zip code, group, contract or tier, making it essential to be exact in your questions and consistent in your tracking.

Verification is no longer just about knowing what's covered. It's about understanding the how, when and under what condition coverage applies. Let's start at the top with verifying insurance. Most claim issues start before the patient even walks through the door. If you're skipping benefit checks, copying cards only, or trusting that last year's data is still accurate.

You're setting yourself up to lose time and money, even if you are a fee for service office. It is very, very important for you to understand what can be covered, what should be covered, and what will be covered. Your verification absolutely has to include group number and subscriber verification.

Frequency clauses for prophy, bite wing, pano fluoride, SRP, downgrades, posterior composites, crowns, and bridges. Missing tooth claws and replacement limitations waiting periods for basic and major and sometimes preventive coordination of benefit status, especially dual coverage patients.

I want you to start by building a system. Have a verification template your team follows. Digitally and consistently use terminology that matches the insurance plan's wording. Don't try to change it to make it easier for the team. Use the words the insurance company uses. Store the benefit data in a shared location, practice management system, or a cloud folder.

A pro tip. Many offices still forget to check sealants, night guards and occlusal guards. These are often limited by diagnosis or age. That small detail could result in hundreds. In denials every month, especially depending on how your office provides services. So next up, let's talk about the real reason you might be resubmitting claims over and over and over again.

And it's not always because someone made some major error or someone did something wrong.  It is often due to not knowing how to preemptively satisfy insurance expectations in 2025, many plans have embedded AI or automation that filters claims by keyword, documentation match and coding logic.

That means your claims need to not just be correct but smartly constructed if you're still submitting with just a code and hoping for the best. This part is for you, and maybe this part is for you if you know that your team is submitting with just a code and hoping for the best. So if you're submitting claims with only a procedure code, you're probably resubmitting 10 to 15% of your claims every month.

And I only know this because we literally have hundreds of dental practices and hundreds of thousands of patients that we literally work on claims for every single month. Complete claims should include the following information, current CDT code, the 2025 version, tooth number surface and quadrant if applic, applicable, digital x-rays or perio charting for SRP or perio maintenance narratives that include diagnosis, symptoms, failed restoration information, aesthetic zone references, provider license, and MPI numbers.

Now, this sounds very rudimentary, but I'm telling you to go back to the drawing board. Whenever I meet with dental practices to build out their SOPs and learn how their practice can become more efficient, we start at the basics. What do your SOPs look like? How is this, how can we make it better? What can we do differently?

 Let me give you an example. Narrative tooth number 30 presents with recurrent decay under existing PFM crown. Patient experiences, temperature sensitivity, radiograph supports crown replacement procedure is medically necessary. Boom. Done. According to a 2024 survey by the National Association of Dental Plans, 42% of claims were denied for crowns and SRP, and that is because they lacked adequate narratives or imaging.

Adding specificity to your claims improves first time acceptance rates dramatically. Another pro tip for you, always submit your UCR fees. We talked about this in the episode just before this. Never submit $0 even on documentation only claims.

Okay, let's move to follow up. This is the part where most offices fall apart, not because they don't care, but because they don't have a rhythm. Claims get submitted and then they're forgotten until someone asks why they haven't been paid, and by that time, you've lost momentum. So I did talk about this process in the previous episode, but I want to dig into how you make this part of your team's DNA.

We implemented this process internally at dentistry support, and the results have been incredible. Our claims are being paid faster than ever, and our rejections have dropped significantly. We follow the 10, 20 30 rule, which means at day zero we submit the claim. At day 10,

we have our first follow up and check on the payer portal. Day 20, we have a second check. If it's unpaid, we resubmit documentation if needed. And on day 30 we do a final check escalating to a rep or a supervisor. Now that means that this is going to have three checks within the first 30 days. Our goal is that your office would have zero to just a few claims aging over 30 days.

And only those with really specific situations. Make it visual. Use color coded trackers in Google Sheet monday.com. Your practice management software. Assign a person accountable for each claim batch. Create a status tag in your system. Sent needs EOB pending X-ray resubmitted. There is a statistic that was just released from Delta Dental and it said that offices that follow up every 10 to 12 days average a 28% faster claim reimbursement than those who wait over two weeks, and it goes down even more when you get past that 30 days.

Coordination of benefits or COB is the area that I believe deserves an episode all by itself. But for now, I want you to think about this. Every claim that involves dual coverage has double the risk for errors, double the risk for delays, and double the risk for denials. If your team doesn't have a documented system, and I mean a flow chart, not just we know what to do, you are not just vulnerable, you are losing money.

And so I want to talk about what works. We're gonna talk about is something you may not have heard before, but let's just get right to it.  It is called the non-standard policy clauses, and they flew under the radar in early 2025. These weren't just changes to codes or reimbursement rates.

These are contractual shifts that quietly started showing up in employer group policies and direct to consumer PPO plans. So what kind of clauses are we talking about? The first one is bundled service exclusions. Some carriers now bundle procedures like oral evaluations and fluoride into one line item, reimbursing for only one, unless you explicitly unbundle them in documentation.

What? Yeah, that really happened. Shared annual maximums across family members. This change especially has been seen in pediatric plans where two children may unknowingly share a maximum and trigger unexpected denials mid-year. The third one is alternate provider caps. So some PPOs now limit coverage if the provider is credentialed under multiple tax IDs or office locations unless noted on the claim.

So here's what to do. Start every new year with a contract review and cross-reference what changed since the previous benefits period. You should have a meeting with your entire team that goes over these items and keep a running list of those changes so that you can be well-informed. Ask for a digital copy of the full benefit summary, not just the coverage snapshot to uncover those hidden terms.

Train your billing team to flag unexpected denials that might indicate hidden clauses and escalate them for rep confirmation. According to data from the NADP, over 17% of policy modifications introduced in 2025 were not disclosed to providers until after the plan year started. These policies are designed to cut carrier costs, but they don't have to cost. Your practice. Awareness is your advantage, and whenever you've heard someone say, we're always learning, I want you to remember that every day is another session in class, and you've got to be updating your team and training as much as you can. Let's shift gears for a moment from the backend systems to patient conversations.

This section of this episode is so important because a lot of what we do in insurance becomes a communication breakdown at the front desk. You can do all the backend verification work correctly, and still lose trust if your team isn't trained to explain it clearly. Teaching your team to confidently speak insurance can be one of the biggest difference makers in case acceptance and revenue.

Patient communication around insurance is just as important as insurance processing itself. The top three patient misunderstandings in 2025 were, why doesn't my insurance pay 100%? I didn't know I had to pay today. I thought it was covered, and I'll come back after I talk to my insurance. You can fix this with transparency.

Use benefit breakdown sheets with estimated co-payments. Verbally explain downgrades and frequency limitations before treatment and include disclaimers. Coverage is not a guarantee of payment. Have your team role play with the top five insurance questions in your next team meeting, add visual aids at check-in and checkout desks.

Provide a written insurance FAQ as part of your welcome packet. It. You have made it this far, and now it's time to zoom out and talk big picture in leadership because all of this knowledge is really great, but if it lives in one person's head or isn't supported by process, it won't scale. Whether you are an office manager, a practice owner, a lead insurance coordinator, or the dentist themselves, your job is to build the bridge between knowledge and repeatable action.

So let's go there. Can we be honest for a moment? If all of this only lives in your head, how will your practice grow? I'm gonna give you a few leadership actions today. Assign one person or one company to own eligibility, one for billing, one for follow-up. Build a weekly claims command meeting to review rejections and approvals.

 Celebrate clean claim wins publicly, then your team stays motivated. Documentation is culture. Keep a master SOP document that includes verification scripts, claim submission, checklists, and coordination of benefit rules. Make updates quarterly with feedback from your team.

Create a Google form or a shared doc for staff to log insurance questions that need answers. If you want to level up even more, bring your entire team to a 90-minute virtual strategy session with me where we evaluate your workflow and show you how to scale with less confusion. All of the links are in the show notes.

Before we wrap this episode up, I want to share one last powerful tool, a current list of known umbrella plans, and their administrative partners. Many billing errors and denials in 2025 are happening because teams are submitting claims to the name on the insurance card, not the actual payer processing it.

This list will save you hours of frustration. Guardian is often processed through Aetna, PPO. United Concordia is often under AX principle, may process through emeritus or Principle plus. Lincoln Financial is frequently administered by Connection Dental, Cigna check for processing through GEHA or GEHA or Connection Dental.

MetLife. PDP plus in some cases is handled by zealous. Humana may process through comp benefits or Dent imax. Don't just rely on the card. Use the group number in a Google search plus the word PPO administrator. Then confirm on the portal  or directly with a rep. This small habit can prevent massive eligibility issues.

Let's recap what we learned today. This is your, that's good moment. Insurance success begins before the appointment with accurate verification. Detailed claim submissions prevent 40% of denials. The 10, 20 30 follow-ups are the easiest ones and the easiest way to speed up cash flow, COB, or coordination of benefit systems must be structured, not assumed.

Your team needs help articulating insurance limitations to patients. Leaders build repeatable systems that grow with practice. If this three part series helped you at all, send this episode to someone in your dental circle. Share it with your team, your manager, or your doctor. We need to normalize clarity and success when it comes to insurance.

And if you need help, we're ready for you. Stay tuned. In the next few weeks, we have an Ask Me Anything Live webinar that's beginning where every week we are gonna come answer your common questions. We are not done supporting you, we are just getting started. I'm Sarah Beth Herman and I'll see you on our next episode of  📍 No Silver Spoons.