In dentistry today, an uncomfortable truth exists behind the scenes: patients often receive different treatment recommendations—not based on science, not based on oral health needs—but based on the type of insurance plan they have.

This isn’t just a financial issue. It’s a clinical one. And it’s time we talk about it.

The Diagnosis Dilemma: When Insurance Influences Care

From PPOs to HMOs to Medicaid, insurance plans vary wildly in what they cover, how much they reimburse, and what hoops providers must jump through. But what’s most concerning isn’t the reimbursement rate—it’s that insurance coverage is quietly influencing diagnosis and treatment recommendations.

When dental teams are asked why one patient receives a composite filling and another an extraction… why one gets a crown and another “watches and waits”… the answer often isn’t clinical. It’s:

“That’s what the patient’s insurance covers.”

Let’s call this what it is: backward treatment planning. It’s the act of filtering care decisions through the lens of coverage instead of science.

And it’s not just a few practices. It’s a culture.

The Culture We Need to Break

This isn’t about calling out individual dentists. Many of them are doing the best they can within a deeply flawed system. But we have to recognize the impact of this insurance-first mindset:

• Patients receive suboptimal care.

• Diagnosis is clouded by financial limitations.

• Dentists feel trapped between ethics and economics.

• Health outcomes suffer.

If our profession continues down this road, we’re no longer guided by evidence-based care—we’re guided by insurance tables.

That’s a dangerous place to be.

What Needs to Change (And Who’s Responsible)

This issue is twofold: insurance companies must change, and dentists must rise.

Insurance Companies Must:

• Make coverage more consistent and transparent across plans.

• Expand benefits to include preventive and long-term health-focused care, not just the cheapest fix.

• Stop setting reimbursement rates so low that quality options become financially impossible for some patients.

• Respect the clinical judgment of providers, not override it with arbitrary benefit decisions.

Dental insurance should support health—not distort it.

Dentists Must:

• Stop pre-filtering treatment plans based on what they think insurance will cover.

• Diagnose based on what the patient actually needs, period.

• Educate patients about their options—even when insurance won’t pay.

• Be brave enough to say:

  “This is the best treatment for your health. Let’s figure out how to make it work.”

This doesn’t mean ignoring finances. It means putting health first and navigating costs second.

A Better Way Forward

We need to create a culture where:

• Diagnosis is based on science, not spreadsheets.

• Treatment plans aim for health, not minimum standards.

• Patients are respected enough to be told the full truth—even if it’s uncomfortable.

This means we must stop saying things like,

“Let’s just do what your insurance covers.”

And start saying,

“Here’s what I see, and here’s what I recommend based on your health. Let’s talk about how to move forward together.”

Final Thought: The Patient Deserves Better

Insurance should never define a person’s health care. And yet, in far too many practices, it does.

Let’s change that. Let’s raise the bar—not just for our profession, but for our patients. Because they’re not “just an insurance plan”—they’re people, and they deserve dentistry rooted in ethics, expertise, and care.

We must stop letting insurance define diagnosis. And we must start defining our profession by the quality and integrity of the care we provide—regardless of who’s paying.

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