How to Become a 'Whistleblower' on Dental Insurance Companies?

For dental practice owners working toward less insurance dependence, understanding the ideas in this article is essential. Here we break down key strategies and actionable steps you can start implementing in your practice today.

And I’m looking forward to, uh, you know, having you there, and hopefully you’ll be able to take a lot of notes from all the experts we’re gonna have.

Gary, let’s jump into today’s episode: How to Become a Whistleblower on Dental Insurance Companies.

What Is a Whistleblower?

Well, I hope we have our listeners’ attention. I’m sure we do. Yeah. Let’s start—let’s start by defining the term "whistleblower." Yes. Now, uh, let’s not assume that everybody listening knows what that term means. How would—how would you define "whistleblower"? And then I’ll give my definition, then we’ll proceed. How would you define "whistleblower"?

I just remember all the TV coverage of one or two people. You know, uh, would you consider Snowden a whistleblower? I don’t know what he did, but he was all over the news. I can’t remember now.

Well, I think "whistleblower," I think the term, uh, uh, means that someone has found something wrong, right? And they brought it to attention. You know, they brought it—something was wrong. Could be, you know, related to a government agency, for example, that, uh, this agency wasn’t doing something right. And, someone discovered it. And, uh, it just was a principled kind of thing that "this isn’t right," and they blew the whistle. You know, they—they blew the whistle to get attention. Right. You know, and to bring out the—bring out the unfairness around whatever was done. And let’s get—so let’s, let’s use that kind of as the definition of a whistleblower: they discovered something that wasn’t right, and, uh, they said, "No, we’ve gotta make this right," and they blew the whistle.

And so there’s a lot of people that think that the dental insurance companies have all the control.

And—and so they go to the, "How am I supposed to do this? How am I supposed to do this? And what am I supposed to do?" And they—they lean on the insurance company for the source of this information, right?

But in fact, there’s a higher power. It’s not the dental insurance company. The dental insurance company—they don’t have the ultimate authority. They have to answer to someone, right? Or something. Uh, "someone" isn’t the right term. They have to answer to something.

Who does the—all dental insurance companies have to answer to? The state Insurance Commission.

Exactly. The state. And remember that—that insurance is state regulated. It’s not federally regulated—it’s state regulated, right? So if they are selling insurance policies in your state, they have to answer to the Insurance Commission.

However, this is where it gets tricky, Naren. The Insurance Commission is not, uh, an agency that looks over and—and takes care of—of—of dental offices, of dentists, or of the employers that buy these policies. They’re a consumer watchdog agency.

Consumer—the—the people that have the policies, the patients that have the policy that’s who the Insurance Commission is ultimately beholden to. Does that make sense?

Real Claim Denial Tactics from Insurance Companies

And then this is where it comes into play. Any of our listeners will know that insurance companies will pull the wool over your eyes when you’re following up on claims.

Hey, well, you’ve had this claim for two months. How come you haven’t paid? Honest to gosh, I have this in my own experience. The clerk at the insurance company will say—back in the day when they used to have printers, and they would print checks, you know, remember? You can imagine that—not electronic deposit to send out payment—they’re printing checks, right? Can you imagine that, Naren?

Uh, I can still imagine. I think, uh, one of my friends, uh, built a billion-dollar company. They just replaced checks with, uh, electronic stuff.

It’s huge—electronic. And that’s where all the insurance companies are going. But back when the insurance companies used to print checks, one—“Well, our printers are down.”

“Our printers are down.” Right. Um, what’s another famous one? “We never received your claim.”

And yeah. How do you—how do you argue with that, right? Like, “We never received your claim.”

Let me tell you how. Okay. Uh, now your claim doesn’t go from your office to the insurance company. It goes from your office to a clearinghouse to the insurance company.

The clearinghouse takes your claim form that was put on Dentrix, Eaglesoft, Open Dental—claim form goes to the clearinghouse. Immediately, the clearinghouse converts it to a UCF—Universal Claim Form.

They then send that to the insurance company, and you can get a transmission report from your clearinghouse on when that claim was sent, right? And so you could say that—so when you’re calling to follow up on a claim, and the clerk says, “We—we—we never received your claim,” you say, “Well, that’s very interesting, because I have a transmission report from our clearinghouse indicating that you received that on the morning of June 6th at 10:42 AM.” Hold, please. And—and then they go running down the hall, uh, and they come back and they say, “We found it.”

“We found it.” Right? Or they ask for an attachment: “We need a perio chart, we need a radiograph, we need a photo.” “Well, I have a report from the clearinghouse indicating that those attachments arrived on the morning of June 6th at 10:42.” Hold, please. They come back and—“Oh, we found ’em. We found—”

But a lot of people that don’t know this will just fall victim to whatever the clerk on the insurance company tells you. “Okay, I’ll resend it.”

Now, if you hit resend, they now have another 30 days to respond.

Understanding the 30-Day Pay or Respond Clause

The—the—the federal law that’s converted to state law says insurance companies have 30 days to pay or respond to a claim.

What’s the part of that clause that really causes us to wrinkle our forehead? What’s the part of that clause?

‘Cause now they can ask for something, and now you—you could—you could fall victim to it.

Technically, it could be 10 years before you get done.

They keep going. They can keep doing it—technically.

The Script: How to Push Back Like a Pro

But here’s what you do, and here’s how you become the whistleblower. And I want you to listen—I want all of our listeners to listen to this. And by the way, the fact that that clause says pay or respond indicates how strong the insurance company lobby is.

That’s how they got that in the regulations.

Because they’re paying billions of dollars for lobbyists to get that kinda language in there.

I just—you know, this is—this is—this is BS. It’s why you need to be off. This is, like—makes you mad.

It’s why you need to be out of network. Okay?

Yeah. But for those of you that aren’t quite ready to do that, then—then let’s become a whistleblower.

And the reason—so whistleblowing is good. Um, ’cause they—they’re taking advantage of you. I mean, when they said their printers are down, do you think that was really true?

No. It’s just an excuse. It’s just an excuse. And they’ll give you excuses. But when you respond back with support—and here’s the support: “The transmission report indicated that you received this on the morning of June 6th at 10:42, and I have that report in hand. And if I don’t have a check within seven days, please know I’ll be advising our patient to file a formal complaint with the State Insurance Commission.”

And—and that check will arrive in your hands in less—you know, first of all, it’s often done electronically—but it will arrive very quickly. But notice the language that I used: If I don’t receive payment within seven days—seven days—and just give ’em seven days—If I don’t receive payment within seven days, we will be advising our patient to file a formal complaint with our State Insurance Commission.

And that strikes the fear of God in the company. Seriously. Because if I say, “We will be filing a complaint,” they put it on mute and start laughing.

Don’t know. Yeah. Because they—they don’t care about dental complaints. They only care about patient complaints.

Insurance Commission pays zero—and it’s not that they—they don’t care. It’s just that’s not their charter.

Patients. The charter is—we’re a consumer watchdog agency. We—the doctor, the office—isn’t part of our, you know, part of our jurisdiction.

Uh, but when you say, “We’ll be advising our patient,” it literally strikes the fear of God. And I’ve been told—and by the way, this—this came up on our 700th episode of the Thriving Dentist Show.

So, little cross—little cross-promotion here. Uh, those of you that may also listen to our Thriving Dentist Show, we just hit episode 701. One of our guests on—we—we invited multiple friends of the podcast to share a quick tip. And the quick tip was: What’s the one thing that you know now that you wish you would’ve learned earlier in your career? And one of our—our guests talked about some things like this, that we—we—we’re talking about now—we’re sharing with you.

Real Consequences for Insurance Companies

Um, so, uh, she made the point of saying the one thing she wished she had known earlier in her career that she now knows is the insurance company’s not in control—the Insurance Commission’s in control.

That was her tip. It was Tessina—I don’t know if you remember her contributing there—but it was Tessina. And, uh, she said, "That’s what I wish I would’ve known earlier, ’cause I’d start doing this stuff earlier in my career."

Uh, so it—it kind of triggered my thinking about doing this podcast episode for LID—for Less Insurance Dependence. So just write down that language: If we don’t receive payment within a week, we will be advising our patient to file a formal complaint with the State Insurance Commission.

Because in every state, if they get a complaint from a consumer, the Insurance Commission is obligated to research it.

And if they research it and—and it has merit, then they—it starts to, you know—the insurance companies do not want to get on the bad side of the Insurance Commission. They—they don’t want to—they want to be invisible to the Insurance Commission. They don’t want to be brought in for these complaints.

‘Cause if they get enough complaints, the State Insurance Commission could—could eliminate their ability to write insurance policies in your state. And that has happened.

That has happened. And this is with very misbehaving insurance companies. And they have eliminated the ability for them to write insurance policies in that state.

Uh, and so that’s the language. And remember—write it down so you know—it’s not we will be filing a complaint, ’cause they just laugh at you on that. ‘Cause they know it will go nowhere.

But, We will be advising our patient to file a formal complaint with the State Insurance Commission.

Now let me—let me add on a—let me bring this back on a positive note. Be a whistleblower when you’re being taken advantage of by the insurance company.

A Positive Note: Recognizing Helpful Insurance Staff

One minute, let me finish this. Be a whistleblower, yes. But I also want to play the other side of the coin, to be fair. I’m asking this rhetorically to our audience: have you ever worked with an insurance clerk who’s been very helpful?

I’ll bet many office managers are nodding their heads yes. Remember, good people can work for insurance companies. Would you accept that on face value, Naren?

Not at the executive level, but at the clerk level—is it possible that a good person could work for an insurance company and be helpful?

Say something like, “Susan, thank you so much. One of my goals is to really help our office with claims processing and insurance, and you’ve been very helpful. Thank you.”

How many times do you think they get thanked on the phone during the day?

Very little. Probably zero. Especially today, when people are all about me, me, me. They don’t thank others.

They don’t get thanked. And when you thank them, they start to feel better. You can say—let’s say her name is Susan—“Susan, can I ask a request? Can I get your direct number and call you directly in the future? Because I love working with you.”

And many times, they have a direct number.

It cuts through the nonsense. Makes it easy for everyone.

The Balance of Advocacy and Kindness

Be kind, be helpful, be appreciative. Mirror it back to them. But when you’re getting the runaround—like “printers are down” back in the day—or just getting garbage answers, then pull out the stick.

And the stick is: If we do not receive payment within a week—and I’m documenting this phone call—we will be advising our patient to file a formal complaint with the State Insurance Commission.

That’s how you become a whistleblower. They do pay attention. If they’re acting up, they’re not trying to be kind, but they realize it’s better to pay you than deal with the consequences of the Insurance Commission, which might result in their loss of the ability to write policies in the future.

Right. So I think the lesson for me is, they will take it as close to the line as possible.

If they can. And your role is to not let them do that.

Or find helpful people within the company that’ll help you. Exactly.

If you tell them you’re going to file a complaint, they’ll laugh. But when you say your patient is filing it with the state insurance commission, that strikes fear into them.

The system isn’t fair, but that doesn’t mean you’re powerless. The more you know, the better you can protect your practice from being taken advantage of.

With over 2,200 coaching clients, Gary has first-hand experience transforming insurance-dependent practices into thriving and profitable practices.