The business of running a dental practice has always been shaped by payers, but the relationship is shifting in new ways, according to one dental CEO.
According to a March 2026 report from the U.S. Government Accountability Office, the three largest dental insurers have a median market share of 66.8%. This consolidation has opened the door to vertical integration, with insurance entities acquiring DSOs and positioning themselves to compete directly with the practices they also contract with.
At the practice level, nearly 80% of dental practices have reported an increase in claim denials or payer scrutiny over the past 12 months, according to a February 2026 report from Zentist. The survey’s respondents who reported more claim denials and payer scrutiny largely attributed these increases to policy interpretations around medical necessity and frequency limitations.
Geith Kallas, DDS, the CEO of Smile Makers Dental Center in Tysons Corner, Va., recently connected with Becker’s to discuss how dental practices can navigate the consolidating dental payer landscape.
Note: Responses were lightly edited for clarity and length.
Question: Given how much economic and policy uncertainty is out of dentists’ control right now, what is one risk, economic and/or policy, that you feel the industry isn’t paying enough attention to? How should dentists be navigating it?
Dr. Geith Kallas: A significant but under-discussed risk for dentistry is payer consolidation. In most states, three to four carriers now control over 70% of the market. Over the past 24 months, two quiet shifts have occurred.
First is vertical integration. The same parent company that insures a patient now owns the DSO down the street. That entity operates as both payer and competitor, with the ability to steer patients, set fees and retain margin on both sides. Second is AI-powered claims management. Automated downcoding, bundling, frequency denials and medical necessity denials are now occurring at scale. Decisions are no longer made by a biller, but by an algorithm that can deny a D4266 when a specific phrase is absent from clinical notes, or that can downgrade a build-up. In many cases, the front desk has no visibility into the reason for denial, and the cost of appeal exceeds the value of the procedure itself. This is not a 5% reduction in UCR. It represents a systematic, largely invisible 8% to 12% reduction in collected revenue on the same production. In many private practices, the biller is still seen as the cause.
There are a few potential paths for navigating this environment:
- From defense to offense on PPOs: A business model that is fully outsourced to major carriers creates structural vulnerability. A clear understanding of true collection percentage by payer and by procedure, and adjusted production per hour by payer, becomes essential for sustainability.
- Development of an independent payer base: A direct membership plan can serve as a strategic hedge, not merely as a discount for uninsured patients. In this organization, patients on the membership plan show 42% higher case acceptance than PPO patients, largely due to the absence of third-party coverage limitations. That base can provide stability during economic downturns.
- Focus on documentation and revenue cycle: The period when strong clinical work alone ensured reimbursement has passed. Payer-proof documentation — detailed narratives, photographs, probing depths and dated radiographs — is now critical. A dedicated resource, whether a person or a system, focused on denial management and trend analysis, functions as a profit center.
- Efficiency as a controllable lever: While policy decisions in Washington, D.C., and fee decisions by carriers remain outside of operational control, cost per hour to deliver care remains controllable. Single-visit dentistry, same-day endodontics, digital workflows and expanded-function auxiliaries contribute to efficiency. An improvement in efficiency compared to five years ago becomes necessary to maintain margin.
The central point is this: waiting for associations or lobbyists to correct reimbursement may not be a viable strategy. A practice model capable of withstanding a 10% fee reduction from the largest payer is positioned to remain resilient in any environment.
