Let’s start with a little story. A real patient walks into your dental office, X-rays in hand, bleeding on probing, and pockets deeper than the emotional trauma of dental school. Classic gum disease. You recommend scaling and root planing. The patient nods, understands the treatment plan, and even schedules the first quadrant.

Then… the phone rings.

“Hi, this is Dr. So-and-So with [Insurance Company], and we just wanted to let you know that your dentist may have overdiagnosed you. You don’t have gum disease. You probably just need a regular cleaning.”

And just like that—poof!—your credibility is gone. Years of training, clinical expertise, chairside trust, patient education… torched by a corporate dentist who’s never so much as looked in the patient's mouth.

Sound familiar?

Welcome to the insurance company’s favorite game: “Diagnose by Distance.” It’s like teledentistry, but without the “tele,” the “dentistry,” or the license to diagnose patients without an exam.

When Insurance Companies Play Doctor (Badly)

In theory, insurance-employed dentists are there to review claims for appropriateness and consistency. But in reality, many have been weaponized to undermine private dentists, push down reimbursement rates, and deny covered services based on cherry-picked X-rays and zero patient interaction.

Let’s break down why this is a massive problem:

Diagnosis Without Examination = ILLEGAL (in many states)

Most state dental boards make it very clear: a proper diagnosis requires a physical exam. If a dentist working for an insurance company never examined the patient, they’re not legally allowed to diagnose anything. They're certainly not allowed to say, “Your dentist overdiagnosed you.” But they do. Repeatedly. Often under the protection of a “peer review” loophole or vague wording.

Patients Lose Trust in Their Actual Dentist

Once insurance plants the seed of doubt, it blooms into full-blown treatment refusal. Patients start thinking:

“Maybe I don’t need this.”

“Maybe this is just about money.”

“Maybe I should get a second opinion from the people who profit by saying no.”

(Hint: they already did.)

Insurance "Dentists" Are Incentivized to Deny Treatment

Remember: these insurance-employed dentists don’t work for the patient. They work for the payer. Their job is to find ways to say no, because denying claims = profit. If they sign off on every SRP, crown, or perio maintenance claim, guess what? Their boss isn’t happy. If they find a way to downcode it, deny it, or delay it, the insurance company keeps more of that premium money.

The Real Diagnosis: A Broken System

Let’s revisit our example.

The treating dentist sees:

Bleeding on probing

5mm+ pocket depths

Radiographic bone loss

Localized inflammation

Poor oral hygiene and risk factors (e.g., smoking, diabetes)

That equals: Chronic Periodontitis → SRP needed.

The insurance “review” dentist sees:

An image that may or may not be diagnostic quality

A chart note that doesn’t tell the whole story

No probing chart

And makes a decision in under 2 minutes, possibly based on whether they’ve hit their “denial quota” for the day.

Then, they call the patient. No examination. No license to treat the patient. Just a magic wand of denial. And guess who suffers? The patient. Not just financially, but medically. Periodontal disease left untreated can lead to tooth loss, systemic inflammation, and complications with diabetes and heart disease.

But sure, let’s take the word of the phone dentist who’s never seen the mouth.

Legal and Ethical Red Flags

Here’s where it gets serious.

🔹 Unauthorized Practice of Dentistry (UPD):

In many states, diagnosing or recommending treatment without a proper clinical exam may qualify as UPD—especially if it influences the patient’s medical decision-making.

🔹 Violations of State Dental Practice Acts:

Several states specify that only treating dentists or those performing in-person evaluations can determine diagnosis and treatment plans. If a “peer review” process results in direct patient communication that alters care, that can violate these laws.

🔹 Interference with the Doctor-Patient Relationship:

Some states (like California and Texas) have passed or proposed laws specifically limiting how third parties (like insurance companies) can influence treatment plans or communicate conflicting medical advice to patients.

🔹 Potential HIPAA Violations:

When insurance company reps call patients directly to discuss clinical findings, there's always a chance they’re disclosing PHI without proper consent or violating privacy rules by misusing that data for non-treatment purposes.

So What Can Dentists Do?

Dentists are not helpless in this. Here’s how to push back:

✅ Document Everything.

When diagnosing gum disease (or anything), chart full probing depths, bleeding points, radiographs, intraoral images, and detailed notes. This creates a defensible record in case of a dispute.

✅ Report Suspected UPD or Ethical Violations.

If an insurance company’s dentist calls your patient and gives a contradictory diagnosis without seeing the patient, file a complaint with your state dental board and state department of insurance. Include your notes, patient statement, and a request for investigation.

✅ Educate Your Patients Preemptively.

Warn patients that insurance companies may try to discredit valid treatment recommendations. Frame it like this:

“Our job is to diagnose based on what we see in your mouth. Insurance companies may review our work to decide what they want to pay for, but they don’t see you. Their opinion is financial, not medical.”

✅ Demand Policy Clarity and Legislative Change.

Encourage your state dental association to push for:

Laws prohibiting non-treating dentists from giving diagnostic advice directly to patients

Greater transparency in peer review processes

Fines for plans that mislead or interfere with patient care

✅ Expose Repeat Offenders.

Some large insurers have track records of meddling with diagnoses. Publicly and professionally calling this out in trade groups, dental boards, or media channels (where appropriate) helps raise awareness.

Final Thoughts: This Is About More Than Money

Sure, insurance companies save a buck when they deny an SRP claim. But the real damage? It’s to the profession. To the doctor-patient bond. To public trust. And most importantly—to the patient who doesn’t get the care they need.

Imagine a cardiologist being second-guessed by a health plan rep who’s never seen the patient’s EKG. Absurd, right? Yet dentists face this kind of sabotage daily.

It’s time to say: Not in our operatory.

Quick Recap

Insurance-employed dentists often illegally or unethically interfere with patient treatment by giving conflicting diagnoses.

This causes mistrust, treatment delays, and real health consequences.

Most states require in-person exams to issue a diagnosis—use this to your advantage when filing complaints.

Document, educate, and advocate to protect your license, your reputation, and your patients.

The doctor-patient relationship should be sacred. Don't let anyone—not even a suit behind a desk—get in the way of that.

If you’ve got a story like this, speak up. And if you’re tired of watching patients suffer because an insurance company decided they’re smarter than your perio chart… you’re not alone.

Need help navigating this mess? Let’s talk. Veritas Dental Resources can help you with insurance pushback strategies, documentation tips, and getting the fees (and respect) you deserve.

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