The Dental Billing Podcast

Less than 1% of denials get appealed in the real world, yet regulators have found appeal reversal rates that should stop every dental office in its tracks. We pull apart what that contradiction tells us: denials are not just “one-off mistakes,” they can be a business model that survives on provider exhaustion, unclear standards, and paperwork loops that quietly delay payment until you give up.

We walk through the hidden source material most billers never read market conduct examinations, consent orders, and enforcement actions where the state audits the insurance carrier and publishes what it finds. From “sequential” documentation requests to denial language that fails to explain what would make a claim payable, these reports turn gut feelings into quotable evidence. We also explain why a fine is effectively a written confession: it shows which behavior could not survive an audit and gives you leverage to reverse engineer your next appeal and escalation.

Then we get practical. Clean claim is a legal term tied to prompt pay law, and understanding it changes how you respond to additional information requests designed to stop the clock. We share two calm questions you can use immediately: ask for the filed policy provision that supports the denial, and ask which licensed clinician reviewed the claim and whether they reviewed the submitted documentation. Finally, we zoom out to pattern recognition: denial rates, overturn rates, time-to-payment, and filing complaints with the right regulator based on plan type, including ERISA self-funded plans and the US Department of Labor.

If you want smarter dental billing appeals and stronger denial management, listen now, subscribe for more, and share this with a biller who is tired of water-gun tactics. What denial pattern are you seeing most in your office?

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Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

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A huge amount of dental practice revenue doesn’t disappear because patients refuse to pay or because insurance “just won’t cover it.” It disappears because someone clicks an adjustment code and the money evaporates without a clear name, a written policy, or a second look. That quiet leak is what I call adjustment slop, and once you learn to spot it, you won’t be able to unsee it.

We start by separating two concepts that too many offices blur together: write offs versus adjustments. Write offs are contractual and tied to your PPO fee schedule. Adjustments are choices, like courtesy discounts, employee perks, hardship cases, marketing promos, or quick “fixes” that make an awkward balance go away. When everything gets dumped into one generic bucket, you lose the story your data is trying to tell. You can’t manage what you can’t see, and you definitely can’t make smart decisions about participation, profitability, or team habits.

Then I walk you through the five types of adjustment slop I see when I take billing departments apart: habit adjustments, cover up adjustments that bury unworked claims, lazy courtesy with no authority, “corrections” that hide posting errors, and bad debt adjustments that happen before real collection steps. You’ll also get my teardown method you can do tonight: pull a 12 month adjustment report, sort by type, and ask one yes or no question for each label: is there a written policy behind this?

If you want your billing reports to be real management tools, not financial guesswork, hit play, pull your report, and start labeling money with intention. Subscribe, share this with your office manager, and leave a review if it helps you stop the leak.

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https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

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Less than 1% of denied dental claims ever get appealed and insurance companies are counting on you to be in the other 99%. I walk you through the denial management mindset shift that changes everything: stop treating the third appeal like the edge of the map and start using the tools that actually hold payers accountable, including your state insurance commissioner for fully insured plans. 

We get practical and specific about what makes a denial “unreasonable” or “bad faith” and how to spot the pattern: benefits are active, eligibility is confirmed, documentation supports dental necessity, and the claim still comes back denied. I also explain why we start with state and federal laws before we obsess over codes, because language like prompt pay, network leasing, and silent PPO issues gives your conversations more weight. Then we clean up common risk areas by separating an honest mistake, a contract violation, and fraud, because mixing those up can put a practice in real trouble. 

From there, we talk tactics: why copy-and-paste appeal templates can work against you in a world where insurers use AI to review claims, and what to use instead. Think ICD-10 diagnosis codes, strong narratives, and patient-specific clinical details that make your claim defensible. Finally, I share documented enforcement examples, including a major fine tied to undisclosed “phantom” frequency limits, and why complaints to regulators compound over time. 

If you want a denial process that protects patients and stops leaving money on the table, listen all the way through, then subscribe, share this with your office team, and leave a review so more billers learn how to escalate the right way.

Sources referenced in this episode:

• Appeal rate / upheld rate: KFF analysis of CMS data — fewer than 1% of denied ACA marketplace claims are appealed; insurers uphold ~56% of appeals (2023 data), 66% (2024 data). Medicare Advantage: ~57% of appealed denials overturned. (On air we used these instead of the "59% upheld because nobody appealed" framing, which conflated the appeal rate with the uphold-on-appeal rate.)
• Delta Dental of Washington: Washington State Office of the Insurance Commissioner fined Delta Dental + its health care benefits manager (Wyssta) $130,000 (Oct/Nov 2024) for, among other things, denying claims based on time/frequency limits not filed with or approved by the state; 7 service types and 50 billing codes had undisclosed limits. Triggered by consumer complaints. This is an actual regulatory fine.
• Self-funded vs. fully insured (the "federal path" mention): The commissioner regulates fully insured plans. Self-funded employer plans fall under federal ERISA law and route to the U.S. Department of Labor (EBSA) instead, not the state commissioner. This is covered in depth in the full denial management talk, not this episode. (Government and church plans are a further exception.)
• Cigna PxDx: 2023 class action (E.D. Cal.), citing ProPublica reporting — ~300,000 denials in two months, avg. 1.2 seconds per claim, "we literally click and submit." Court allowed the case to proceed March 2025 (abuse of discretion). This is litigation, not a fine — described on air as a lawsuit/court ruling.
• UnitedHealth nH Predict: Class action (D. Minn.) alleging a 90% error rate on the AI tool and that ~0.2% of policyholders appeal. Court ordered algorithm disclosure in 2026. Allegations in active litigation — stated as such on air.
• The "0.2% will appeal" motive appears in both the Cigna and UnitedHealth complaints as an allegation of intent.

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Support the show

Grab the FREE End of Year Revenue Push Playbook Here:

https://link.captivationhub.com/widget/form/rHoSnbSvVMeFH4V2GFsf

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
[email protected]

Email Jen:

[email protected]

Dental billing can look smooth from the outside, but that “smooth” is usually one person doing a mountain of detailed, high-stakes work behind the scenes. We’re sharing a quick, focused message about Dental Billers Appreciation Day and why it matters for every practice that depends on clean claims, accurate coding, and steady collections. 

You’ll hear how a conversation with Qiana Craig (Ask the Biller) about Medical Billers Appreciation Day sent us down a research rabbit hole and revealed something surprising: dental billers didn’t have a day of their own. So we created one. That story opens up a bigger theme we live by in dental office administration and practice management, if you don’t see the space you need, build it. 

We also get real about what the job requires: deep organisation, constant follow-up, tech skills across modern billing tools, and the discipline to keep up with changing codes and systems in today’s dental economy. Dental revenue cycle management doesn’t run on luck, it runs on expertise. Dental Billers Appreciation Day is July 20 every year, so mark your calendar and do something meaningful for the person who helps keep your practice financially healthy. If this resonates, subscribe, share it with your team, and leave a review so more dental offices start giving billers the credit they’ve earned.

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Grab the FREE End of Year Revenue Push Playbook Here:

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Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
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Email Jen:

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Your insurance AR report is trying to tell you the truth, but most of us only glance at the total and walk away with more anxiety than clarity. I’m Erica Aguilar, and I’m breaking down how to read the story behind the numbers so you can tell, with real confidence, whether your dental billing department is performing well or quietly leaking time and money.

We start with the biggest mindset shift: dollars alone don’t equal performance. I’ll show you how to turn each insurance AR aging bucket into a percentage so you can compare month over month and spot patterns that individual claims can’t reveal. You’ll get clear dental billing KPIs and benchmarks, including what “healthy” looks like when 92% of your insurance money is paid within 30 days, and why a heavy 90+ day category should trigger curiosity, not panic. From there, we talk through the questions that uncover root causes like late claims, missing attachments, delayed clinical documentation, weak claim construction, and payers that keep pushing you past state prompt pay laws.

We also widen the lens beyond insurance AR. I explain why patient AR tells a different story, why the credit balance report can expose compliance issues and unclaimed property risk, how to trend denials by payer and CDT code, and how poor fee schedule maintenance can inflate write-offs and create bad patient balances. Then we get practical with the claims correction list, the simple tool that creates visibility where most practices have none.

If you want a concrete next step, I give you homework to pull your key reports, start tracking denial reasons, and implement the free claims correction list from the show notes. Subscribe, share this with your office manager or biller, and leave a review with one question you want your reports to answer next.

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Grab the FREE End of Year Revenue Push Playbook Here:

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Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

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I want to share something with you this week that I don't usually talk about.

For years, Jen and I carried an idea we couldn't shake. We knew dental billing better than almost anyone, and we kept saying the same thing to each other. Somebody needs to fix this. Eventually, we realized that somebody was us.

What followed was not a clean, easy story. We flew to Arizona and locked ourselves away to get everything out of our heads and onto paper. We sat across from one of the most respected people in dentistry and got advice that was brutal, the opposite of what I wanted to hear. We turned down money that was on the table because we wanted full control, no holdbacks. And there was a stretch where it got so quiet that someone close to us asked if we had given up.

I'll be honest with you. There was a moment I wondered if I'd made the wrong call.

In this week's episode, I'm taking you all the way behind the scenes. The offers we said no to, the advice that changed everything, the doubt I rarely admit out loud, and the moment a room full of dentists showed me it was all worth it. I'm documenting this whole journey on purpose, so that you can learn from it too.

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Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

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Email Jen:

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Twenty browser tabs. Constant timeouts. Portals that never match your workflow. If you’ve ever felt like dental billing is less about skill and more about surviving fragmentation, we’re saying the quiet part out loud and giving you a clearer path forward. Jen and I unpack the “command center” concept: the practical system that pulls critical billing knowledge out of sticky notes, personal notebooks, and one overwhelmed team member’s memory, then turns it into a shared, durable source of truth.

We talk through what actually belongs in that command center so a practice can run with consistency: credentialing and CAQH details, NPIs and tax IDs, portal access and payment methods, EOB and EFT storage, end-of-day reporting, and a structured billing meeting framework that gives the doctor real visibility beyond “what’s in the bank.” We also dig into the cultural side of billing performance, including why doctors often measure the wrong things, why billers feel personally attacked by questions that should be normal, and how simple structures like pre-meeting forms and situational reports change the tone and the outcomes.

Then we shift into what we’re building next. Insurance has used AI in claims adjudication for decades, and too many practices are still fighting denials with manual work, copied templates, and hours of chasing. We share what we’re beta testing now: an API-integrated billing command center designed to reduce the grind by automating pieces like EFT retrieval, eligibility, claim tracing, denial tracking, and appeal letter generation, so the biller can spend more time making decisions and less time hunting for data. If you want to see what it looks like, grab the link in the show notes, join the wait list, and book a quick demo, then subscribe, share, and leave a review so more practices can stop running billing on hard mode.

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Support the show

Grab the FREE End of Year Revenue Push Playbook Here:

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Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
[email protected]

Email Jen:

[email protected]

A claim can be created in seconds, but a defensible claim takes verification and that difference can make or break your reimbursement. We start with a tough question: if a dental claim is a legal document, why are so many practices submitting claims before anyone confirms the clinical documentation actually supports what’s being billed? When speed becomes the priority, compliance and cash flow both take the hit.

We zoom in on the insurance reimbursement cycle and redefine where it truly begins: the moment treatment is rendered, not when the claim is submitted. From there, everything depends on the clinical record being complete and accessible, from notes and narratives to X-rays, intraoral photos, and periodontal charts. I explain why clinical documentation is defensive documentation, the record that speaks for the provider during audits, disputes, or fraud allegations, and why billing teams should measure what prevents claims from being created, not just what’s already aging.

Then we break down the claims correction list, a pre-aging visibility tool that tracks completed treatment that cannot enter the reimbursement cycle yet. Unlike insurance A/R, denial, and production reports, it exposes the invisible money sitting in limbo and helps you spot patterns like chronic delayed notes, repeated missing attachments, or workflow handoff gaps. You’ll leave with a simple seven day challenge to document every reason a claim cannot be created and use that data to build predictable billing outcomes.

Subscribe, share this with your office manager or lead biller, and leave a review if it helps. What’s the most common reason your claims get stuck before submission?

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Grab the FREE End of Year Revenue Push Playbook Here:

https://link.captivationhub.com/widget/form/rHoSnbSvVMeFH4V2GFsf

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
[email protected]

Email Jen:

[email protected]

You can have hardworking people and still have a billing department that feels like a black box. Claims get submitted, denials appear, balances age, and everyone assumes follow up is happening, but nobody can point to where the work actually stalls. We dig into the “workflow engine,” the third pillar of the Fortune Billing Department Framework, and show how visibility is the missing link between dental production and predictable collections.

We walk through the practical tools that turn vague frustration into clear data. The big one is the claims correction list, a simple but powerful way to track why claims are not moving through the insurance reimbursement cycle. Insurance aging reports tell you what is overdue, but the claims correction list tells you the real reasons: incomplete clinical notes, missing narratives, missing x rays, additional information requests, and repeat documentation gaps that create denial patterns. When you can name the bottleneck, you can train, coach, and fix the process instead of chasing balances.

From there, we layer in daily and monthly rhythms that keep the revenue cycle healthy: an end of day billing report that creates real time communication between the billing team and leadership, plus a monthly billing meeting where trends become strategy and decisions are made by facts instead of assumptions. We also talk about building a structured billing calendar with owners and deadlines so “I’ll get to it when I have time” stops costing you money.

If you want your dental billing workflow to run like a system, press play, then subscribe, share this with your office manager, and leave a quick review so more practices can build predictable billing outcomes. What is the number one thing you suspect is slowing your claims down?

Send us Fan Mail

Support the show

Grab the FREE End of Year Revenue Push Playbook Here:

https://link.captivationhub.com/widget/form/rHoSnbSvVMeFH4V2GFsf

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
[email protected]

Email Jen:

[email protected]

Send us Fan Mail

Support the show

Grab the FREE End of Year Revenue Push Playbook Here:

https://link.captivationhub.com/widget/form/rHoSnbSvVMeFH4V2GFsf

Get your Dental Billing Toolkit Here:

https://www.dentalbillingdoneright.com/the-dental-billing-toolkit

Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:

https://docs.google.com/forms/d/e/1FAIpQLSfxnnfSlNd0NPhMoBWq-1D_xU5R8LS4xPhHNKIjfLQwStOUag/viewform?usp=header

Schedule a billing chat with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min

Email Ericka:
[email protected]

Email Jen:

[email protected]