Artificial intelligence to fix dental insurance


My thinking about how artificial intelligence (AI) technologies will improve dentistry, if not fundamentally revolutionize dentistry, has broadened considerably in recent years.

As Lou Shuman, DMD, CAGS, explained in his February 2019 article Dental economics opinion piece, “How Artificial Intelligence Shapes Dentistry,” we are a long way from Hollywood’s view of AI-powered humanoid robots.1 However, a range of AI technologies are already in use today in the form of computer software. AI-powered software automates routine tasks that are typically performed by humans. Sophisticated AI technology platforms can learn to unearth information and find patterns in complex systems and vast amounts of data. Computer vision AI, in particular, holds promise for healthcare as it enables image content to be analyzed with superhuman speed and precision.

As a dentist seeking the potential of cutting edge technology, my thoughts on AI initially tended to pass through a narrow clinical lens: how will AI benefit me what about dental clinicians like me? I would think about how AI could enable hyper-precise, accountability-free diagnoses and super-intelligent treatment plans. I would imagine perfectly fitting dentures and increased patient confidence, and I would finally see oral medicine integrated into systemic health care.

But it didn’t occur to me that AI could have a substantial impact on dental insurance beyond its obvious application to automating insurance claim submission.

Today I would say insurance is an area where AI will prove to be extremely beneficial for our industry, and sooner rather than later. From what I see, it is clear that AI applications for dental insurance could have as big an impact on the dental industry as a whole as it is on the delivery of treatment.

In fact, while AI applications for diagnostics and practice management are still under intense regulatory scrutiny, insurers in other industries are already benefiting from AI. According to the Center for Insurance Policy and Research, artificial intelligence “is currently used in complaints handling, underwriting, fraud detection and customer service.”2 Auto insurers use AI-powered virtual assistant chatbots to answer customer questions 24/7 with natural language, saving time and money. Machine learning and computer vision AI enables insurers to estimate and forecast costs faster and more accurately by analyzing data from historical information, sensors and claims images.

Why dental insurance needs AI

Dental insurance is the economic engine of our industry. Let’s face it, though we hate to admit it, when the dental insurance industry suffers, we all suffer.

First, dental insurance companies can claim much of the credit for integrating scientific and technological advances into the practice of dentistry, thanks to the fact that they allow massive consumption of dental care. Certainly, every practicing dentist can attest to the fact that most patients will refuse advanced treatment options if their insurance does not pay a significant portion of the bill.

In addition, most practicing dentists can attest to the fact that, as financial controllers, insurance companies’ claims handling systems often arbitrate the quality and timeliness of patient care, as claims handling determines the quality and timeliness of patient care. willingness of patients to accept treatment. In fact, it was this aspect of the insurance equation that I first considered when examining the short-term benefits of AI for dentistry.

Previously, my considerations (and, yes, my frustrations) as an attending physician with insurance companies overlooked the insurer’s perspective. As dentists we look at how claims are handled and see a system that at best slows us down and at worst aims to cheat us. If we step back and swap the lens, the grim, bureaucratic hassle we see in handling claims start to look like an unfortunate but essential safeguard of the industry.

As it stands, fraud and overdiagnosis, along with waste and human error in the claims process, are creating a drag on insurers. Unfortunately, we know only too well that a few dishonest dentists can really screw the system up for the worse. Atlantic The magazine recently covered a story of blatant dental insurance fraud and concluded that our profession is inherently vulnerable to fraud.3 However, I know bad apples are the exception in our field, not the rule. It’s time to change history.

Consider that a large insurance company can receive some 40 million claims per year. No insurance company, regardless of its size, has the manpower to review so many claims. In truth, only a fraction of claims are adjusted manually (I’ve heard estimates in the range of 3% to 5%), and the rest are decided by methods that seem downright arbitrary and random. In reality, most claims are not decided by a trained professional, but rather by informed mathematical models which by their very nature will statistically mark some good claims as unfounded and some bad as valid.

It is on this last point that we – and our patients – are frustrated. But if insurance companies blindly accepted every claim, then fraud, waste and abuse would bankrupt the financial backbone of our industry, and we would lose the only official intermediary between doctor and patient who helps insure. proper alignment between diagnosis and treatment. Let’s not forget that fraud, waste and abuse don’t just cost insured patients and dentists. This is costing taxpayers billions in Medicaid system costs. Anyone can agree that this is a problem worth addressing.

So how do you reconcile the issues that physicians face when dealing with insurance companies and the issues that insurance companies face when dealing with physicians?

The Whole Truth: Oral Imaging, AI, and Precision in Dentistry

Oral imaging is both the primary diagnostic evidence on which we prescribe treatment and the primary evidence on which insurers assess claims. This is also the area of ​​dentistry where AI can deliver the most immediate results through computer vision. In fact, AI systems based on computer vision technology for the analysis of oral images are on the way to overtaking the diagnostic capabilities of humans.

AI Computer Vision Oral Imaging Diagnostic Systems will soon deliver super accurate results at superhuman speed and bring clarity of truth to dental insurance. They will guarantee doctors fair treatment from insurance companies, protect insurance companies from dishonest doctors, and give patients peace of mind when dealing with doctors and insurers.

What we can expect from AI for dental insurance

No claims left behind—Manpower will no longer limit the number of complaints that are subject to a certain level of review, as the AI ​​will assess all oral imagery accompanying each complaint. Assessment results can be used to assess the likelihood of a claim being approved, allowing insurance companies to quickly and intelligently determine which claims need to be reviewed manually and which need to be approved quickly.

Prevent insurance fraud, waste and abuse—When all the images associated with the claims are analyzed, the fraud, waste and abuse in dental insurance claims will be largely eliminated. AI can detect cases of resubmission fraud in which dentists repeatedly submit a single image representing a particular condition or submit the same image to multiple insurers.

AI can also signal potential cases of overdiagnosis and misdiagnosis. Cleaning up diagnoses will reduce costs for everyone, reduce liability for insurers and physicians, and mitigate risks for patients. And, of course, AI can instantly notify doctors when they mistakenly submitted the wrong image.

Automatic evaluation before complaint—AI will ultimately enable full integration between dental practices and insurance imaging systems, providing real-time claims assessment and transparency of pretreatment costs.

The AI ​​that evaluates the images on the spot and communicates the results to the insurer will allow insurers to immediately notify doctors whether the insurance will cover the prescribed treatment and, if so, how much the insurance will pay.

Automatic pre-claim assessment is truly AI’s holy grail for dental insurance. It will bring initial financial clarity and diagnostic validation to an area of ​​medicine that has often been criticized for its lack of both. Clarity of costs and validation of diagnoses will also provide an ancillary benefit to patients, as they are more likely to receive the right treatment when diagnoses and the financial aspects of treatment are discussed openly, in real time.

For fairly obvious (but not always correct) reasons, insurance companies tend to hold a place of dishonor in the hearts of dentists and patients. But like it or not, insurance is the financial engine of the dental industry. Anything that makes this engine more efficient will benefit dentistry as a whole. This is why AI insurance applications will potentially revolutionize the dental industry as much as its therapeutic applications.

The references

1. Shuman L. How artificial intelligence shapes dentistry. Dental economics website. Posted on February 1, 2019.

2. Artificial Intelligence. Website of the National Association of Insurance Commissioners. Posted on September 13, 2019. Updated on December 23, 2019.

3. Jabr F. The Truth About Dentistry: It’s a lot less scientific – and more prone to free procedures – than you might think. Atlantic magazine. Published in May 2019.

Kyle Stanley, DDS, maintains a private dental practice in Beverly Hills, California. He is the Clinical Director of Pearl, a company that provides practice-oriented artificial intelligence solutions for patients, practitioners and insurers. Download the guide “Open wide: How AI is reshaping the future of dentistry” at to learn more about how AI will improve the dental industry and oral health.


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