What Insurance Isn’t Telling You (But Your Dental Team Needs to Know in 2025)

By Sarah Beth Herman, CEO of Dentistry Support®

Dental insurance policies are more confusing than ever in 2025. While most practices think they’re “in the know” because they verify coverage or use a patient portal, the truth is—many teams are still in the dark when it comes to what actually gets claims paid.

As someone who has spent nearly 25 years supporting dental offices, I created this free training blog as a must-read before you listen to Part 2 of my No Silver Spoons podcast series on dental insurance. This article will give you the context and awareness your team needs to get the most from the episode and—more importantly—to improve your insurance workflow immediately.

If you’re a practice owner, office manager, or anyone working in eligibility or dental billing, this blog is your wake-up call. Let’s break down what’s really happening behind the scenes with insurance in 2025—and what your team should do about it.

1. Why “Covered” Doesn’t Mean “Paid”

One of the most common issues I see in dental offices is the assumption that if something is “covered,” it will automatically be reimbursed. That’s not always true.

Insurance Reps Are Not Required to Share Certain Details. Most reps will confirm that a code is “covered,” but won’t tell you:

If the code has frequency limitations (e.g., 1 per 12 months vs 2 per calendar year)
If the service is subject to downgrade
If a pre-authorization or specific documentation is needed

Example: A claim for a posterior composite is submitted, but the plan downgrades it to an amalgam filling. If you don’t submit a proper narrative and include “alternate benefit applied” language, the claim might be underpaid or denied.

Solution: Train your team to ask the deeper questions. Include these in every insurance call:

“What are the frequency limits for this code?”
“Is this procedure subject to an alternate benefit?”
“Is a pre-auth or x-ray required for this code?”

2. Frequency and Downgrades—Still a Problem in 2025

You’d be surprised how many denials still occur due to frequency issues, even though they’ve been a known challenge for years.

According to MetLife’s 2024 Claims Guide, 36% of rejected preventive service claims were tied to frequency conflicts. These include prophys, fluoride, and bitewings done too soon—even if the patient “hadn’t used it yet this year.”

Also, many PPOs still downgrade composite fillings to amalgam, especially on molars. This includes:

D2391-D2394 (posterior composites)
D2740 (ceramic crowns)

What’s new in 2025 is that more plans are enforcing downgrades based on aesthetic zones. That means if a tooth isn’t visible in the smile line, they might downgrade your composite or porcelain crown—even if you’re providing superior care.

Old-School Tip That Still Works: Attach an intraoral photo or state “visible in the esthetic zone” in your clinical narrative.

3. The Complexity of Coordination of Benefits (COB)

COB continues to be one of the top three causes of claim denials in 2025. Many teams either don’t understand the rules or submit the claims in the wrong order.

Here’s a crash course:

Birthday Rule: The parent whose birthday (month and day) is earlier in the year has the primary plan for a child
Carve-Out Plans: Some insurance plans only pay what they would have if they were the primary plan
Non-Duplication Clauses: If the primary paid 100%, the secondary pays nothing
Divorce Rule: The custodial parent’s plan is primary unless a court order states otherwise

What You Should Do:

Always get the EOB from the primary plan before submitting to secondary
Confirm the COB rules directly with both carriers
Train your team to ask for divorce decrees if parents are separated
Create a written workflow for all dual coverage scenarios in your office

COB issues aren’t just administrative—they directly impact cash flow and patient trust.

4. Why Claims Sit Unpaid—And How to Fix It

Every week, I speak to a practice that says, “We’re waiting on $30,000 in claims.” And every time, it’s the same root problem: small, preventable errors.

According to Delta Dental’s 2025 Claims Trends Report:

41% of delayed claims are due to missing clinical documentation
27% are denied for lack of pre-authorization
15% are resubmissions with outdated CDT codes

Common Bottlenecks:

Not attaching x-rays, perio charts, or clinical notes
Submitting the wrong revision year for CDT codes
Forgetting NPI or provider license number
Failing to follow up in the first 10 days

How to Fix It:

Use a claim submission checklist for every procedure
Train your clinical team to chart with billing in mind
Assign someone to follow up every 10 days after claim submission (not 14!)

Want even more support? You can schedule a 90-minute virtual training session with me or one of our insurance experts, where we will walk your team through YOUR specific claims and show you exactly where the bottlenecks are.

5. Non-Covered Services Clauses—Your Practice Might Be Losing Money

Let’s talk about something no one likes to bring up: non-covered services fee limitations.

Some PPO contracts limit how much you can charge for procedures they don’t even cover. Sounds unfair? That’s because it is.

The good news is that in 2025, more states are pushing back against this with new legislation like the Dental and Optometric Care Access Act. If adopted nationwide, this will give providers the freedom to charge full fees for services not reimbursed by insurance.

What You Should Do:

Review your PPO agreements with a legal or insurance consultant
Know your rights—especially in states already implementing new laws
Clearly explain non-covered services and fees to patients before treatment

Pro Tip: Transparency builds trust. Patients don’t get upset when you explain the “why” behind their bill.

Final Thoughts Before You Listen

This episode of No Silver Spoons is packed with knowledge that builds on the truths we’ve explored here. We’re peeling back the curtain on insurance—because if you don’t understand it, you can’t lead your team through it.

If any part of this training blog made you think, “We need help with this,” you’re not alone.

You can:

Join me for a 90-minute private training session
Enroll your team in Dentistry Support Academy for front office training on all of these topics
Attend our upcoming live AMA (Ask Me Anything) webinar for real-time answers to your insurance questions

Links for all three are in the show notes of the podcast episode and available on our websites. You don’t have to go it alone—and you shouldn’t.

Your patients deserve a team that’s informed and confident. Your office deserves to get paid. Your team deserves the tools that make that possible.

Now go hit play on the episode. Let’s level up together.

References & Resources:

MetLife Dental Provider Guide (2024): https://www.metlife.com/dental-insurance/
Delta Dental Claims Submission Guidelines: https://www.deltadental.com/us/en/dentists/claims-submission.html
ADA CDT 2025 Codes: https://www.ada.org/publications/ada-catalog/cdt-products
NADP Trends & Legislation: https://www.nadp.org/Reports/ResearchBriefs.aspx
Dentistry Support® Academy: https://www.dentistrysupportacademy.com
Schedule with Sarah Beth Herman: https://www.sarahbethherman.com

Disclaimer:

To learn more about Sarah Beth Herman, the author of all free training content you can read her bio here. These materials are intended to provide helpful information to dentists and dental team members. They are in no way a substitute for actual professional advice based on your unique facts and circumstances. This content is not intended or offered, nor should it be taken, as legal or other professional advice. You should always consult with your own professional advisors (e.g. attorney, accountant, or insurance carrier). To the extent, Dentistry Support ®has included links to any third-party website (s), Dentistry Support ® intends no endorsement of their content and implies no affiliation with the organizations that provide their content. Further, Dentistry Support ® makes no representations or warranties about the information provided on those sites. You can view our privacy policy and terms and conditions by clicking those pages in the footer of our website.