📍  Welcome back to No Silver Spoons. I am Sarah Beth Herman, and today's episode is a leadership episode, it's also a really important one for your dental practice. We are going to talk about what is happening in the dental insurance world as we move into 2026. This episode will include carrier updates, benefit realities, and how dental practices should be thinking about verification.

Billing. And communication. Before we get into it, I want to say something upfront. Some of what I'm going to share today may sound basic to some of you. You might think we already know this, that is common sense, but here's what I have learned. After working with hundreds of dental practices all over the United States, over three decades, not every dental office operates the same.

Not every team is trained the same, and not every dental leader has the same exposure to how dental insurance truly works behind the scenes. So I am approaching this conversation with care with what I call kid gloves. My goal is not to talk down to anyone.

My goal is to make sure we are all on the same page, and my hope is that even if you hear things you already know, you'll still walk away having learned something new, something clarified, and something you didn't think about recently. One quick, important disclaimer. This episode is for educational and leadership purposes only.

It is not legal advice, compliance advice, or a guarantee of insurance payment. Dental benefits vary by carrier, employer group, and individual plan Coverage decisions are made by the insurance company at the time a claim is processed. Also, when I reference CDT codes, I want to be very clear and respectful.

The CDT code set is published by the American Dental Association and it is copyrighted. I am not reading descriptors or reproducing the CDT manual. I am referencing publicly available summaries and discussing changes at a high level. For full and official descriptors. Practices should always refer to the official CDT 2026.

Resources from the A DA. Alright, let's get into it. As leaders, we have to understand this. Insurance changes are not just billing team issues. They affect case acceptance, patient trust, how confidently your team presents treatment, cash flow, and the overall stress level inside your practice.

In 2026, there were 60 CDT changes, effective January 1st, 2026, including additions, revisions, deletions, and editorial changes. That alone should tell you something. This is not just a set it and forget a year. Let's start high level dental insurance carriers like Delta Dental, Cigna, and MetLife have released updated 2026 plan materials.

Benefit summaries and processing guidance. Here is what is important to understand. These insurance companies are not saying we are changing everything what they are saying is, use the 2026 materials for 2026 states of service Verify benefits every year.

Don't assume last year's rules still apply. Understand that plan design varies by employer and tier. This matters because assumptions are where practices lose money.  Delta Dental has published updated 2026 plan brochures and group plan notices, including updates for individual family group and federal plans.

Delta has also updated its Medicare Advantage Dental Partnerships for 2026. So what this means for practices is simple, but very critical. If a patient says, I have had Delta Dental forever. Your team should hear this is still a new plan year. The leadership takeaway is all of our software must be updated for 2026 CDT codes.

Deleted codes should not be used for 2026. States of service. Pre-authorized templates should reflect the current language and Medicare advantage. Dental plans should always be verified individually. Okay, Delta is very clear that coverage varies by plan design. Even under the same carrier name, Cigna has released 2026 dental plan summaries.

That fact sheets show continued trends we've seen, but with important nuances. Many Cigna plans still show that preventative services are covered at 100% in network. Deductibles are applying to basic and major services and annual maximums that vary by tier waiting periods are depending on employer plan, so keep an eye on that.

And then there are some higher tier plans that include implant coverage this year, increased annual maximums over time, so maybe last year they only covered $1,500 annual maximum, but this year it's now $2,000. And they have adjusted exclusions compared to older plans. So your leadership reminder here is that Cigna is a perfect example of why your team cannot memorize coverages.

We see that in dental offices all the time. Our team members who have been in dental for 5, 10, 15 years, they automatically say, oh, I know how that plan works. Oh, that plan does this. That's not the case this year. Two patients with Cigna may have very different dental benefits. Let's move on to MetLife.

MetLife's 2026 dental plan summaries continue to highlight. Negotiated in network savings. Now I know there have been a mass exodus of dental offices who are going fee for service and out of network with all insurances. This is where you want to keep track of things because even if you're out of network, we can't have that nonchalant or dismissive response to patients that, Hey, we'll still bill your insurance, but you're paying upfront right now.

We can't just treat every patient like that. Things are changing, and I want you to preserve that relationship.  There are differences between in-network and out-of-network reimbursements and also where the money is being paid to. Deductibles and co-insurances are varying by category. And then annual maximum structures are changing based on plan and employer.

Some of the 2026 plan designs show changes such as expanded implant coverage when they have a higher tier plan, and then adjusted exclusions or missing tooth provisions. So your leadership takeaway here is MetLife, plans, reward, accuracy, and verification, and clarity and communication.

 If you are listening and taking notes, this is a great time to pause this podcast, take notes, talk with your team, even rewind what you've heard already. Or think, should I bring this podcast episode to my next morning huddle or team meeting? This is a great reference point for you. Free information for your dental practice, things that you wanna be looking at in verification, dental, billing, and communication with your patients.

Feel free to pause here and we will resume after your break.  Okay, let's continue now. Let's talk briefly about CDT changes without getting lost in the code soup, there are, were deletions, revisions, and additions in 2026. One of the biggest practical takeaways for leadership is this codes were cleaned up to reduce confusion.

That means fewer, almost the same codes, and then more emphasis on documentation clarity. And less room for creative interpretation. For example, preventive or restorative coding scenarios were simplified, meaning documentation should focus on diagnosis, services, and clinical reasoning.

Rather than trying to force language to fit a code, your leadership message to your doctors and your clinical team is this. Document what you did and why you did it. Let the code follow the care. The anesthesia and sedation category saw significant clarification for 2026. First, these are your three key factors you want to remember.

Time, increments matter.  Agent type matters and documentation matters. If sedation is part of your practice, this is not optional education. Here is your leadership checklist. One, start and end times clearly documented. Two level of sedation identified. Three agents used, documented four. Monitoring and recovering notes included, and five.

Medical necessity. Clearly stated, if your documentation does not match the code type. You are setting yourself up for denials and audits and I want to mention that your office, even if you do all the right things, you will never be able to 100% prevent audits or denials, but what we want to do is prevent the possibility or lower the probability that you may have these things occur for your practice.

Here is another great place to pause for note. S if you're taking notes or discussing this in a huddle, this is a great moment to pause the podcast and rewind listening to the five steps in the checklist I just gave you. Now, let's talk about breakdown of benefits, because this is where everything comes together.

Now. I talk to dental practices every day, all day, and nearly every day of the week. We are always discussing the use of ai, the use of various softwares and systems that connect to your practice management software or utilizing services that automatically verify benefits.

I'm going to put a strong emphasis of caution to using any of those softwares, especially in the beginning of the year. I have tested out nearly every single software that exists out there that has AI attached automation attached, or some sort of integration into dental software, and I have yet to find any software that can do this, like the human can here at Dentistry Support.

We provide this service for dental offices. And we do this by hand on the phone, researching all of the information, especially in the beginning of the year when there are brand new changes, many dental insurances are still not fully updated. With that, proceed with caution First of all. Breakdown of benefits is not just a phone call.

It is a system at a minimum. This is the list of things your team needs to make sure is verified. If you are using a third party system such as dentistry support, please make sure you take the time to review with your team. All the things that they're doing. If you need a quick list, a reference point of what your third party team should be doing, you can head to dentistry support.com and at the very top of our website lists all the 2026 updates you need to be aware of.

If you want to know more about our services and how we provide this service for dental practices, you can also schedule a call to learn more. Sometimes it's just nice to compare services and make sure you're getting everything you should be getting in verification this is not a train it once and your team will always know it and you never have to visit it again. So let's talk about the system. At a minimum, your team should be verifying the following eligibility and effective date. Annual maximum and remaining maximum deductible and remaining deductible Coverage, percentages by category, frequency limitations, waiting periods, missing tooth clauses, downgrades or alternative benefits.

Whether a pre-authorization is recommended or required, and any procedures under any categories that you frequently bill under where a code may have been changed. This is not about being perfect, but it is about being consistent. Your eligibility verification should be done for every new patient, for every new plan year, for every visit.

The patient comes into when a new month has rolled over for every high dollar procedure. For every Medicare Advantage patients, every visit here is your leadership tip. If a patient's insurance card says the same thing as it did last year, that does not mean the plan is the same. This also rings true if your patient's insurance card says the same thing this month that it did last month.

If you are only completing a full breakdown of benefits once a year, it is not enough. , Plans are changing by the week. Fee schedules are changing by the month. There are changes constantly happening to insurance employers are constantly looking to lower expenses.

They're changing what they're offering their employees, even if it's not during open enrollment time. Please make sure your team is doing a full breakdown of benefits, every patient, every time, and updating everything inside of your system. Next, we want to talk about some simple front desk scripting.

Your team needs language that is calm and confident. Here is a great example. We have verified your dental insurance benefits for this year. Dental plans vary a lot, so your estimate is based on the information provided by your insurance. Once the claim is processed, we will review it together and adjust it or communicate with you if needed.

If there's a balance left over and you are concerned about that, we would love to have that conversation with you. But please remember, your dental insurance is a contract between you and the dental insurance company. We are merely submitting claims on your behalf. We cannot determine the way an insurance company will pay.

But we are committed to making sure we give you the most accurate and up-to-date estimate. Another way you can say this is your plan may cover an alternate procedure or a different percentage than what our doctor has diagnosed. We will walk through all options so you can make the best decision for you.

These scripts protect trust. If you are upfront and you communicate well and confidently, you will not have to worry about a patient being upset about a balance due. I want to pause here and share something important. This episode is sponsored by Dentistry Support. Dentistry Support provides virtual administrative support for dental practices across the country, and I want to say this clearly.

Our current clients of record are already operating with updated 2026 workflows. Their breakdown of benefit processes have been adjusted. Their billing teams are aware of the 2026 CDT changes and carrier expectations. Their systems reflect what's happening now, not what worked five years ago. This is what structure looks like.

This is what preparation looks like, and this is why leadership matters in administrative systems, not just clinical care. From a leadership perspective, your billers should be focused on clean claim submission, working all of your claims every 10 days, documentation alignment, accurate code usage, timely follow up, no claims, aging over 30 days, and understanding payer specific processing quirks from an eligibility standpoint, your team should be verifying before promising documenting verification details.

Setting expectations clearly and never guaranteeing coverage. This protects your practice and your team. This is a great moment in this podcast to pause for note taking and discussions with your team. Feel free to pause or rewind this podcast episode and come back to listen for the next section.

Let's continue. Here's the truth. You will never have a perfect dental insurance system, but you can have a prepared one. You can have teams that understand the landscape. You can have leadership that sets clarity, and you can have reduced surprises instead of reacting to them. Insurance is not the enemy, but misunderstanding it is.

 So let us all stay positive as we navigate dental insurance. I know there is a huge stigma and there is a lot of negativity that revolves around how they pay when they pay, and the rules that come along with that. Let's make sure we understand what we know, because we can't change their minds on how they handle their payouts, how they handle their reimbursements, or how they process claims.

So let's understand it to the very best of our ability. In every episode, we always have a that's good moment where we recap the most important portions of our training that we provide on our podcast. Awareness is leadership. Preparation reduces chaos. Verification builds trust, documentation protects revenue and clarity allows your practice to grow with confidence.

If you want to slow down this episode or speed it up, remember you can adjust the playback speed on your podcast app. If this episode helped you, please leave a review on Spotify, apple Podcast or iHeartRadio. If you'd like to work with dentistry support in 2026, you can check the show notes for a link to schedule a call to learn more about our virtual services for dental practices.

Thank you for being here. Thank you for leading well, and please check out our free training@dentistrysupport.com slash free training. For a full list of our 2026 CDT codes and updated narratives for your practice. As always, our training on our website that is available for you now is free. You are welcome to connect with us as well to learn more about our virtual or intensive onsite training for  📍 your dental practice.

I'll catch you on the next episode.