The Letter That Can Cripple A Dental Practice

And Why More Dentists Are Getting It Than You Think

It never starts the way you expect. There’s no phone call. No warning. No conversation. Just a letter.

In early 2025, an Ontario dentist—let’s call him Dr. X—received just such a letter from an insurance company. At first glance, it appeared procedural. Standard language. Administrative in tone. But buried in that letter was a clear message:

Your practice is under investigation.

From Review to Reckoning

The insurer cited its obligation to ensure that dental benefits are being used appropriately, it referenced its right to request patient information, and it noted concerns about billing patterns.

Then came the details. Pages of them and specific codes were being questioned:

• Emergency exams
• Crown-related procedures
• Gingivectomies
• Recementing
• Periodontal appliances

But this wasn’t a short-term audit. The review reached back eight years.

Think about that. Eight years of decisions. Eight years of habits. Eight years of patterns—now being dissected and analyzed.

The Response That Wasn’t Enough

Dr. X did what any responsible clinician would do. He had no choice and he responded with a 91-page submission, including:

• Detailed clinical explanations
• Patient-by-patient breakdowns
• Radiographic support
• Justifications for every questioned procedure

Then came more requests for more documentation which meant more time pulled away from patients, staff, family, and running a business.

Months passed and then came the second letter.

On July 22, 2025, Dr. X was informed that effective July 25 the insurer would no longer accept claims from him or his clinic. Three days’ notice!

There was no gradual transition, no meaningful recourse, no second chance.

He was delisted.

What Happens After Delisting

Many assume that if they can prove their clinical rationale, they can resolve the issue. That assumption is dangerously uninformed.

In Dr. X’s case:

• Legal counsel was engaged
• Over $31,000 was repaid
• A formal appeal was submitted

The outcome was that the appeal was denied and the delisting upheld and, his clinic still remains locked out.

A Growing, Silent Problem

Unfortunately, cases like this are no longer isolated, and across Canada—particularly in Ontario and Alberta—delisting is increasing.

So why haven’t you heard about it openly? Because, for most dentists, this is not just a compliance issue, it’s reputational, it’s financial, and it’s in fact existential. Those closest to the issue—lawyers, investigators, and industry insiders—estimate that the number of affected dentists is in the hundreds.

Dentistry didn’t suddenly become less ethical, and clinicians didn’t suddenly become less competent. What has changed is how insurers evaluate risk.

For decades, claims were reviewed individually and now they are being analyzed collectively.

Insurance companies now use:

• Artificial intelligence
• Large-scale data modeling
• Cross-provider comparisons

They are no longer asking “was this procedure necessary?” They are asking “Does this provider behave differently than their peers?”

 

The Shift Dentists Haven’t Fully Grasped

This is the critical shift, you are no longer being evaluated case-by-case, you are being evaluated as part of a pattern.

That means:

• Consistently billing at the high end—even if justified—can trigger concern
• Slight inconsistencies across providers can create statistical outliers
• Documentation gaps, even small ones, become amplified over time
• Time vs. procedure mismatches raise immediate flags
• In multi-dentist clinics, all procedures billed under one dentist

And perhaps most concerning, you cannot see what they see. Most dental practices operate with limited insight into their own data patterns. They rely on clinical judgment, team habits, and perhaps periodic manual reviews

But insurers are reviewing years of data simultaneously, thousands of claims and providers at once, and patterns invisible at the practice level. So, while a dentist sees individual patient care the insurer is seeing a statistical profile.

When the Letter Arrives, It’s Already Too Late

By the time a practice receives an audit letter the analysis has already been completed, the patterns have already been flagged, and the risk has already been assessed, so at that stage, the process is no longer exploratory, it is confirmatory and, in many cases, the outcome is largely predetermined.

So far there aren’t any legal remedies available.

The impact is immediate—and devastating with a significant reduction in practice value; complications in selling or financing the practice; patient loss; and reputational damage. A career built over decades is fundamentally altered in months.

 

The Dangerous Assumption

Most dentists believe “if my treatment is appropriate, I’m protected” but that is no longer true because appropriateness is not what is being measured. Patterns are.

Every practice should now be asking:

• Are our codes always aligned with actual time and treatment?
• Are we unintentionally creating patterns that appear abnormal?
• Is our documentation consistently supporting our billing?
• Do all providers follow the same standards?
• Do we know how we compare to industry norms?

If the answer to any of these is unclear then you may be at risk.

The traditional approach—manual chart audits and periodic reviews—is no longer sufficient because it cannot track patterns across years, compare providers in real time, detect subtle statistical anomalies, or align documentation, time, and billing consistently.

The New Standard: Continuous, System-Driven Oversight

Forward-thinking practices are now adopting software-driven systems that:

• Continuously monitor procedure code utilization
• Identify outliers before insurers do
• Align treatment, time and billing automatically
• Standardize care across providers
• Ensure documentation supports every claim
• Create defensible records in the event of an audit

This is no longer a “nice to have.”

It is becoming a requirement for survival because this is the new reality, you are not just running a dental practice, you are operating within a data-monitored environment where every claim contributes to a long-term profile, every inconsistency compounds over time and every pattern is being evaluated. And if you are not actively managing that profile you are leaving your practice exposed.

The most dangerous moment for any dentist is not when they receive the letter it is the years before—when everything appears normal, your production is strong, your patients are happy and nothing seems wrong. Because that is exactly when the data is being built so that when the letter finally arrives it is no longer a warning, it is a consequence.

 

The Bottom Line

In today’s dental environment clinical excellence is no longer enough and data awareness is essential. The practices that will survive—and thrive—are the ones that recognize this shift early and act before they are forced to.

You need to utilize your own computer systems, combined with appropriate software that can forestall the insurance company algorithms that are being run on your claims history.

Otherwise, it may already be too late.

How Tier Three Can Help

At Tier Three, we understand that today’s dental environment requires more than strong clinical care and production. Practices need operational oversight, documentation consistency, risk awareness, and systems that help protect long-term practice value.

Our team works with dental professionals across Canada to help identify operational vulnerabilities, improve practice systems, and strengthen overall business readiness in an increasingly data-driven environment.

Whether you are preparing for growth, planning a future transition, or simply looking to better protect the practice you’ve spent years building, proactive oversight is no longer optional—it’s essential.

To learn more about protecting and strengthening your practice, visit TierThree.ca.

A past President of the Canadian Dental Association, the Ontario Dental Association, and the Ottawa Dental Society, Dr. Bernie Dolansky has played a pivotal role in conceiving and implementing CDAnet and iTrans, Canada’s national electronic dental claims service.  As a Senior transition consultant at Tier Three Brokerage, currently Dr. Dolansky assists dentists with transition planning, practice evaluations, practice sales and purchases. He also serves as a business advisor for RNA180, a platform designed to support accurate and appropriate code usage. He can be contacted at bernie.dolansky@tierthree.ca.