When Insurance Denies Medically Necessary Care: Where Dentists Can Turn for Help
As a dentist, you advocate for your patients every day — not just clinically, but financially. It’s frustrating, even infuriating, when a patient’s urgent, medically necessary treatment is denied by their insurance despite the plan stating it’s covered. You’ve likely experienced this situation:
Pre-treatment estimate says “covered”
Treatment is performed and documented thoroughly
Claim gets denied — often with vague or contradictory reasoning
The patient is confused, upset, and facing an unexpected bill
At some point, it stops looking like an administrative error and starts to feel like claims processing fraud or abuse — particularly when insurers seem to routinely block access to care patients are entitled to under their paid plans.
So what can you do? Is there anyone holding these companies accountable?
Yes. There are several government agencies and advocacy paths available — and as a provider, you have a right (and arguably a responsibility) to pursue them.
First: Recognize the Signs of Possible Insurance Misconduct
The plan says a procedure is “covered,” then systematically denies the claim
Insurers request unreasonable documentation, then deny based on "insufficient info"
Medically necessary, urgent treatment (infection, trauma, severe pain) is delayed or blocked
Claims are denied without valid explanations (e.g., vague “not medically necessary” denials)
The denial appears to contradict the plan summary or pre-treatment estimate
When this becomes a pattern — especially across multiple patients or claims — it may rise to the level of claims suppression, bad faith processing, or consumer fraud.
Who Can You Contact for Help and Advocacy?
1. Your State Department of Insurance
Most states regulate both medical and dental insurance. File a complaint on behalf of the patient or encourage the patient to do so.
They can investigate benefit denials, review insurer behavior, and impose penalties.
Be sure to submit:
Treatment documentation
EOBs
Any pre-treatment estimates
Correspondence with the insurance company
Find your state’s DOI here: https://content.naic.org/state-insurance-departments
2. State Attorney General’s Office (Consumer Protection Division)
Insurance companies that misrepresent benefits or deny legitimate claims may violate consumer protection laws.
Report possible insurance fraud, false advertising, or bad faith denial of benefits.
Patients can file a consumer complaint; you can submit on their behalf with written authorization.
3. The U.S. Department of Labor (For ERISA Plans)
If the patient’s dental benefits are part of a self-funded employer-sponsored plan (often large companies), they fall under ERISA regulations.
The U.S. Department of Labor (DOL) regulates these plans.
ERISA requires that denials be clearly explained and appealable. If the insurer is violating this, you or the patient can file a complaint.
https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa
4. The National Association of Dental Plans (NADP) & ADA Council on Dental Benefit Programs
While they don’t regulate insurers, these groups track trends, advocate for reform, and may be interested in data if systemic abuse is occurring.
You can submit reports or documentation that support industry-level advocacy.
The ADA’s Dental Insurance Issues form is a place to report concerns about bad faith denials and payer behavior.
ADA’s insurance resources: https://www.ada.org/resources/practice/dental-insurance
5. State Dental Board (If Insurers Are Interfering With Clinical Judgment)
Some states allow dentists to report insurers that interfere with the doctor-patient relationship or violate practice laws by delaying urgent care.
While not always the best first step, it’s worth exploring if harm is being caused by benefit denial.
Tips for Filing a Strong Complaint or Report
Be factual, clear, and organized
Include patient’s written consent (HIPAA compliant)
Attach:
Benefit verification printouts
Pre-authorizations or pre-estimates
Denial letters or EOBs
Treatment notes and diagnostic evidence
Identify how the insurance action contradicts their own stated coverage or policies
Final Thoughts: You Are Not Alone
Insurance companies should not act as gatekeepers to treatment patients urgently need — especially when the coverage has been paid for and documented.
As a provider, you have every right to advocate fiercely for your patients. And with the support of regulatory agencies, professional organizations, and public pressure, you can help push back against unfair insurance practices — not only for your patient, but for the greater dental community.
As a dentist, you advocate for your patients every day — not just clinically, but financially. It’s frustrating, even infuriating, when a patient’s urgent, medically necessary treatment is denied by their insurance despite the plan stating it’s covered. You’ve likely experienced this situation:
Pre-treatment estimate says “covered”
Treatment is performed and documented thoroughly
Claim gets denied — often with vague or contradictory reasoning
The patient is confused, upset, and facing an unexpected bill
At some point, it stops looking like an administrative error and starts to feel like claims processing fraud or abuse — particularly when insurers seem to routinely block access to care patients are entitled to under their paid plans.
So what can you do? Is there anyone holding these companies accountable?
Yes. There are several government agencies and advocacy paths available — and as a provider, you have a right (and arguably a responsibility) to pursue them.
First: Recognize the Signs of Possible Insurance Misconduct
The plan says a procedure is “covered,” then systematically denies the claim
Insurers request unreasonable documentation, then deny based on "insufficient info"
Medically necessary, urgent treatment (infection, trauma, severe pain) is delayed or blocked
Claims are denied without valid explanations (e.g., vague “not medically necessary” denials)
The denial appears to contradict the plan summary or pre-treatment estimate
When this becomes a pattern — especially across multiple patients or claims — it may rise to the level of claims suppression, bad faith processing, or consumer fraud.
Who Can You Contact for Help and Advocacy?
1. Your State Department of Insurance
Most states regulate both medical and dental insurance. File a complaint on behalf of the patient or encourage the patient to do so.
They can investigate benefit denials, review insurer behavior, and impose penalties.
Be sure to submit:
Treatment documentation
EOBs
Any pre-treatment estimates
Correspondence with the insurance company
Find your state’s DOI here: https://content.naic.org/state-insurance-departments
2. State Attorney General’s Office (Consumer Protection Division)
Insurance companies that misrepresent benefits or deny legitimate claims may violate consumer protection laws.
Report possible insurance fraud, false advertising, or bad faith denial of benefits.
Patients can file a consumer complaint; you can submit on their behalf with written authorization.
3. The U.S. Department of Labor (For ERISA Plans)
If the patient’s dental benefits are part of a self-funded employer-sponsored plan (often large companies), they fall under ERISA regulations.
The U.S. Department of Labor (DOL) regulates these plans.
ERISA requires that denials be clearly explained and appealable. If the insurer is violating this, you or the patient can file a complaint.
https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa
4. The National Association of Dental Plans (NADP) & ADA Council on Dental Benefit Programs
While they don’t regulate insurers, these groups track trends, advocate for reform, and may be interested in data if systemic abuse is occurring.
You can submit reports or documentation that support industry-level advocacy.
The ADA’s Dental Insurance Issues form is a place to report concerns about bad faith denials and payer behavior.
ADA’s insurance resources: https://www.ada.org/resources/practice/dental-insurance
5. State Dental Board (If Insurers Are Interfering With Clinical Judgment)
Some states allow dentists to report insurers that interfere with the doctor-patient relationship or violate practice laws by delaying urgent care.
While not always the best first step, it’s worth exploring if harm is being caused by benefit denial.
Tips for Filing a Strong Complaint or Report
Be factual, clear, and organized
Include patient’s written consent (HIPAA compliant)
Attach:
Benefit verification printouts
Pre-authorizations or pre-estimates
Denial letters or EOBs
Treatment notes and diagnostic evidence
Identify how the insurance action contradicts their own stated coverage or policies
Final Thoughts: You Are Not Alone
Insurance companies should not act as gatekeepers to treatment patients urgently need — especially when the coverage has been paid for and documented.
As a provider, you have every right to advocate fiercely for your patients. And with the support of regulatory agencies, professional organizations, and public pressure, you can help push back against unfair insurance practices — not only for your patient, but for the greater dental community.
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
