If you're a solo dentist or run a small private practice, you’ve probably felt it — that sense of helplessness when dealing with frequent insurance denials, delayed reimbursements, and vague EOB excuses.

“I feel like a small fish in a big pond.”
“How can I fight back when I’m just one office and they’re a billion-dollar insurance company?”

It’s a valid frustration. The truth is, the insurance industry often counts on dentists feeling too small, too tired, or too busy to push back.

But here’s the good news: You’re not powerless.
There are practical, legal, and strategic ways to fight back — and win — even as a solo provider.

Let’s break it down.

First, Recognize the Pattern

If you’re seeing a spike in:

• Claim denials for “lack of medical necessity”

• “Bundled” services that reduce reimbursement

• Missing documentation claims (when it was sent)

• Downcoding without clinical justification

• Delay tactics and repeated requests for resubmission

You’re not alone. These aren’t isolated glitches — they’re part of a broader systemic trend as insurers tighten their margins and lean on algorithms to cut costs.

The key is not to accept it as “just how it is.”

Step 1: Get Relentless with Documentation

Insurers look for weak points. If they can deny a claim due to “missing” or “incomplete” documentation, they will.

Best practices:

• Always include clear clinical notes, tooth numbers, radiographs, diagnosis codes, and narratives — even for common procedures.

• For higher-risk codes (SRP, crowns, buildups, implants), submit everything upfront.

• Use detailed, patient-specific language. Avoid copy-paste notes that trigger red flags.

Sample narrative: “Tooth #19 presented with fractured mesial cusp and secondary decay. Pulp vitality test showed lingering pain. Full coverage restoration necessary to preserve function and prevent fracture propagation.”

Step 2: Use Their Own Regulations Against Them

Even as a small office, you have rights. Insurance companies must follow state and federal rules. Start leveraging:

State Departments of Insurance

File formal complaints for:

• Repeated, unexplained denials

• Delays in payment

• Violations of prompt-pay laws

• Failure to honor pre-treatment estimates

Most states allow you to file online. These complaints must be investigated.

Escalate Internally

Call insurance reps and ask for:

• Appeals supervisors

• Provider resolution units

• Claim auditors

Keep detailed logs:

• Dates, names, call reference numbers, and summaries.

When you act organized and persistent, they take notice.

Step 3: Send Strong Appeal Letters (and Don’t Give Up)

Too many offices never appeal — and that’s what the insurance companies hope.

When you appeal:

• Be concise but firm.

• Reference clinical standards of care, ADA procedure codes, and medical necessity.

• Use templates, but personalize each appeal.

Pro tip: Appeals are often reviewed by different departments — sometimes even by licensed clinicians. Use that to your advantage.

Step 4: Join Forces with Other Dentists

There is power in numbers. As a solo provider, you may feel small — but you’re not alone.

• Join your state dental association or local dental society

• Participate in insurance committees or payer issue panels

• Report patterns to organizations like the ADA’s Council on Dental Benefit Programs

These groups compile data and fight back at a policy level. Your voice adds to the momentum.

Step 5: Track Your Denials and Use the Data

Start a spreadsheet or dashboard:

• Denials by code

• Denials by carrier

• Denials by reason

• Resolved vs. unresolved

You’ll start to see patterns. And when you do:

• Use that data to renegotiate PPO contracts

• Drop repeat offenders (lowest-paying plans with highest denial rates)

• Show your team where better documentation can prevent issues

“What gets measured, gets managed.”

Step 6: Reclaim Your Leverage

Insurance companies need in-network providers to market access to care. If you’re:

• In a competitive area

• Seeing high patient volume

• Offering specialty services (implants, sedation, full arch)

...you have more leverage than you think.

Don’t be afraid to:

• Renegotiate your fees (especially after providing 12+ months of data)

• Leave low-paying plans and keep patients out-of-network

• Offer your own membership plan to create independence

Final Thoughts: You’re Not Small — You’re Strategic

Yes, insurance companies are massive. Yes, they’re frustrating. But you’re not just a “small fish.” You’re a skilled, educated healthcare provider with rights, resources, and the power to push back.

You don’t have to be loud — just consistent.
You don’t have to go to war — just document, appeal, escalate, and advocate.

The more dentists take action — even small, daily steps — the harder it becomes for insurance companies to deny legitimate care.

Benjamin Tuinei

Founder - Veritas Dental Resources, LLC
Phone: 888-808-4513

Services:
PPO Fee Negotiators | PPO Fee Negotiating | Insurance Fee Negotiating
Insurance Credentialing | Insurance Verifications

Websites:
www.VeritasDentalResources.com | www.VerusDental.com