By Bernie Dolansky DDS

What Letter?

In January 2025 Dr. X, an Ontario dentist, received a letter from an insurance company, which I will refer to as “AnyCompany” stating that:

“As an insurer and administrator of group benefits, AnyCompany has an obligation to our plan sponsors and plan members to ensure that their dental benefit dollars are being spent properly and that service providers and patients are utilizing benefits appropriately.”

“Our analysis and ongoing investigation of procedure code utilization from your office have raised concerns that we will be addressing. Your cooperation in this matter and timely communication is expected and will help prevent any interruption in your ability to submit dental claims to AnyCompany.”

“AnyCompany’s contracts reserve us the right to request patient information. Our contractual guidelines, claim forms, and electronic claim submission agreements authorize the review of clinical information. Each of your patients have provided you with their consent to share clinical information by accepting and utilizing their insurance plan in your dental office.”

What followed was six pages of details and questions about claims submitted as far back as 2017. These included queries about the use of specific and emergency exam codes; codes for restoring teeth prior to crown placement; gingivectomy codes; recementing crowns; and periodontal appliances.

On January 25, 2025, the dentist sent a detailed 91-page reply explaining, on a patient-by-patient, procedure-by-procedure basis, with supporting radiographs, exactly what was done and the rationale for treatment.

There were further requests for more information in February and March, with the requested additional information provided by the dentist.

On July 22, 2025, Dr. X received a letter from AnyCompany stating that as of July 25, 2025, AnyCompany would no longer accept any claims from him or any providers associated with his clinic.

He was delisted!

After the July 22nd letter, Dr. X sought help from a lawyer with a great deal of experience in dealing with dental regulatory matters. This lawyer reached out to the insurer numerous times over the ensuing months to no avail.

On Oct 10 AnyCompany sent a four-page letter outlining its review of Dr. X’s complaints with dollar figures included and requested repayment of $31,382.03.

Dr. X paid and his lawyer then requested an appeal from the insurer. On Nov.11 the appeal was rejected.

Since then, Dr. X has engaged the services of a lawyer with an extensive background in dental litigation. As of this writing he and his clinic remain delisted.

How Extensive Is This Delisting Problem?

Presently all the reported cases involve two Canadian dental claims administrators, with most of the cases so far concentrated in Alberta and Ontario.

It is difficult to pinpoint exactly how many dentists have been affected by delisting, as practitioners aren’t eager to talk about, but anecdotal evidence from lawyers, dental associations, and dental forensic investigators suggests that the number is in the hundreds.

Now, according to the Canadian Dental Association, there are more than 25,000 dentists in Canada so this number may seem small. However this could be a canary in the coal mine, so it is important for dentists to be proactive and prepared.

What Defense Is There If I’m Delisted?

As can be seen from the case history of Dr. X, not a lot.

From a legal perspective a dentist doesn’t have any contractual relationship with the insurance company, that relationship is between the plan sponsor and the insurer, so delisting isn’t a breach of contract with the provider.

As well, by submitting a claim, as the insurer stated:

“AnyCompany’s contracts reserve us the right to request patient information. Our contractual guidelines, claim forms, and electronic claim submission agreements authorize the review of clinical information. Each of your patients have provided you with their consent to share clinical information by accepting and utilizing their insurance plan in your dental office.”

Based on conversations with the involved parties, great inconsistency has been reported in how delistings have been resolved; some dentists are delisted as individuals; sometimes an entire clinic and all providers are delisted; sometimes money is repaid and the delisting continues as it was for Dr. X; and in some cases, after the money is reimbursed, the delisting is reversed.

What Are The Consequences?

The economic and reputational fall-out from delisting can range from bad to devastating.

In Dr. X’s case AnyCompany had coverage for 20 per cent of his patients, meaning that there was a 20 per cent hit to his revenue and certainly a much greater hit to his practice’s value. In addition, there was also the reputational damage done in his community.

Delisting will have a very material, consequential effect on a practice’s sale-ability and sale price with some Dental Service Organizations now putting conditions around delisting in their purchase agreements.

Delisting has the potential to literally wipe out a lifetime of professional and financial accomplishments.

What Is Driving Delisting?

Private dental insurance has been available for decades and has been the foundation for delivering superior oral health care to the vast majority of Canadians.

From those very first days, the claims adjudicators have carried out their fiduciary responsibility to plan sponsors by auditing claims to weed out providers that have not fulfilled their professional responsibility to act in an honest manner.

For decades, dentists have focused on clinical excellence, patient care, and running efficient practices. But today there is a new risk emerging — one that many dentists are completely unaware of until it is too late.

Insurance companies are no longer simply processing claims. They are analyzing behaviour.

Massive data sets are now being reviewed using artificial intelligence to identify patterns that fall outside statistical norms.

And when a pattern is flagged, the consequences can be severe:

• Multi-year claim reviews
• Repayment demands
• Delisting from insurance carriers
• Patients forced to seek treatment elsewhere
• Significant loss of practice value

For many dentists the first warning sign arrives after years of claims have already been analyzed. By that point, the damage may already be done.

The Uncomfortable Reality

Many dentists have no idea how their practices appear to the algorithms reviewing their claims.

They assume that if their treatment was clinically appropriate, their practice is safe.

But insurers are not evaluating treatment decisions in the operatory. They are evaluating patterns in data.

And those patterns may or may not reflect the clinical realities dentists face every day.

Which leads to the most important questions every practice owner should have always asked, and they continue to be critical in this new world of data analysis:

• Is my treatment valid and does the claim that I submitted accurately reflect what was done?
• Are my chart notations detailed enough to always validate treatment provided?

If the answer to either question is no or maybe, then the practice may already be at risk.

What Should You Be Doing?

Appropriate billing is not only about protecting yourself, but it is about ethics and dentists’ duties to their patients.

Dentists should always refrain from:

• Inappropriate use of procedure codes
• Billing that is not supported by your detailed clinical records

Dentists should:

• Verify that time billed is appropriate based on the code used
• Verify that time billed is supported by clinical records
• Bill for the time spent, which will vary from patient to patient
• Verify that all procedure codes are submitted using the treating dentist’s Unique Identification Number (UIN)

Using another dentist’s UIN would put you in violation of your CDAnet User Agreement.

Summary

1. Verify that the time billed is appropriate for the code used and not always billed to the maximum.
2. Verify that the charts accurately reflect and corroborate the time spent on the procedure that is being coded.
3. Avoid routine use of excessive/maximum billing practices.
4. Claims should not be billed under the Unique Identification Number (UIN) of one dentist.

It is very important for every practice to have robust mechanisms for managing billing practices to ensure ethics, follow legal requirements, and avoid audits and clawbacks.

Forward-thinking dentists should now begin to utilize the full capability of their existing software systems or acquire systems that:

• Monitor procedure code utilization
• Identify statistical anomalies to support ethical practice, before insurers do
• Ensure that documentation supports billing
• Proactively defend their practice if questions arise

In the new insurance environment, hope is not a strategy.

Preparation is.

The dentists who will survive and thrive in this new environment will be the ones who understand the risks early — and take steps to ensure they are following the rules, and protecting their practices from a delisting catastrophe before the first letter arrives.

If you are unsure how your practice appears from an insurance analytics perspective, it may be time to start asking those questions now.

Before someone else does.