When Advocacy Works: A Model for Endodontists Navigating Insurance Barriers and Securing Proper Claim Resolution

By Dr. Kayla Tavares Tio, D.D.S., M.D.S.

Insurance carrier misalignment and improper claims processing have become increasingly common sources of strain within endodontic practices. Many providers find themselves caught in cycles of delays, repeated resubmissions and inconsistent information. My practice recently confronted such a challenge when Carrier A and Carrier B failed to honor our timely Carrier A network opt-out and continued to process claims under the incorrect fee schedule.

After months of unsuccessful attempts at internal resolution, the matter was finally corrected—swiftly and decisively—once the Texas Department of Insurance (TDI) became involved. Within days, all claims were reprocessed correctly.

This experience highlights a clear pathway for other endodontists facing similar obstacles: a structured advocacy model grounded in documentation, professionalism and strategic escalation.

The Problem: A Timely Opt-Out Ignored

In January, our practice submitted the required Carrier A opt-out documentation. Despite completing the process, claims continued to return under the Carrier A/Sun Life fee schedule instead of our specially contracted fees. We contacted both Carrier A and Carrier B repeatedly, resending documentation multiple times. Each interaction produced shifting timelines—first 30 business days, then 60, then 90 and eventually 120. Throughout this period, Carrier B maintained that no opt-out was on file.

The issue persisted for months without progress, significantly increasing our administrative burden. Each attempt to correct the problem was met with vague assurances, inconsistent explanations or new waiting periods. Meanwhile, claims continued to process incorrectly.

The Turning Point: Regulatory Oversight

After exhausting all internal channels, our practice submitted a formal complaint to the Texas Department of Insurance. Once TDI reviewed our documentation and contacted Carrier A, the issue turned around almost immediately. Carrier A updated our network status, acknowledged the opt-out and reprocessed all affected claims—something customer service could not resolve over nearly half a year.

This rapid correction underscores the impact of regulatory involvement. Insurance carriers often respond quickly when contacted by state oversight agencies, and regulators take network accuracy and claim integrity seriously.

Conclusion

Advocacy is not only necessary—it works. By following a structured model supported by proper documentation, persistence, professional collaboration and regulatory oversight when warranted, endodontists can overcome carrier barriers and ensure accurate claim processing. This experience stands as a practical and repeatable model for our specialty.

A Structured Model for Endodontists

This experience revealed several steps that may serve other endodontists well.

1. Build a strong documentation foundation.
   Every form submitted, every EOB received, every call made and every email exchanged should be recorded and organized. Accurate CDT code definitions, specialty standards of care and clinically detailed narratives reinforce code appropriateness and reduce ambiguity.
2. Communicate clearly and consistently.
   Carrier communication should be factual and firm. Clearly state what treatment was performed, why the CDT code is correct and what action is required. Request written confirmation, not verbal assurances.
3. Leverage professional organizations.
   When routine channels stall, the AAE and ADA provide valuable support. Their guidance reinforces correct coding and strengthens the provider’s position.
4. Escalate when necessary.
   If an insurer remains unresponsive—even when provided with correct documentation and explanations—the next step is escalation to the state insurance commissioner. This formal, consumer-protected pathway exists specifically for situations where insurers improperly process claims or fail to act. Regulators can intervene, compel corrective action and ensure carriers follow contractual and statutory obligations.

Documentation Tips That Strengthen Your Position

Strong documentation plays a decisive role in successful dispute resolution. Endodontists should:

• Keep detailed records of all calls, including dates, times, representatives and promised follow-up steps.
• Maintain concise, clinically accurate narratives aligned with specialty standards.
• Retain copies of all claim submissions, EOBs and network correspondence—both electronic and scanned—to create a traceable paper trail.

When preparing a regulatory complaint, clarity is essential. Summaries should outline the issue, timeline, attempts at resolution and the specific action requested. Providing well-organized evidence enables regulators to intervene efficiently and confidently.