Whether you are enrolled in a dental insurance plan or are shopping for a new one, the choices you make can affect what you'll pay out-of-pocket. Knowing the difference between which dentists are in-network and which are out of network can help you save you money and reduce paperwork.
What is an in-network dentist?
An in-network dentist is a dentist who has contracted with your insurance company to provide dental services. Usually, you will pay less out of your own pocket when you receive care from in-network providers.
Insurance companies work with dentists all over the United States to provide as many options for their policyholders as possible. The companies ask dentists to sign a contract saying that they will provide a certain discount for the fees for dental services to the company’s policyholders. Some agreements are for a certain percentage of fees; other contracts require a flat fee guarantee. Whatever form the contract takes, the dentist and the insurance company work together to make sure you get the best dental services and the lowest fees possible.
In return for discounted fees, in-network dentists become the preferred providers for all the company’s policyholders. This helps increase the dentist’s business and helps the dentist gain more regular patients who return again and again for dental services. A win-win-win for the patients, the dentist, and the insurance company.
What is an out-of-network dentist?
An out-of-network dentist is a dentist who is not contracted to provide services under your insurance plan. You will usually pay more out of your own pocket for services at an out-of-network dental office.
Some dentists will join a network if their patient’s ask. If your employer changes dental insurance plans and you do not see your dentist listed in the network, do not hesitate to discuss the problem with your dentist.
When evaluating a new dental insurance plan, find out if you are restricted to only seeing in-network dentists. Preferred provider organization (PPO) plans allow you to see both in-network and out-of-network dentists, but your insurance company will likely pay a lower rate for out-of-network dentists and you will be responsible for the difference. Dental health maintenance organization (DHMO) plans do not provide coverage for out-of-network dentists.
Why should I go to an in-network dentist?
As you have already seen, there are many advantages to using an in-network dentist for you and your family’s dental care needs. But the benefits go beyond simply saving money.
Less hassle for you
In-network dentists have a relationship with the insurance company, understand their forms and codes, and are comfortable filing claims on behalf of the patient. The company sends payments directly to the dentist. You receive a notice showing how much the dentist charged for services, how much the plan paid, and the amount of any remaining copays or deductibles. Since the in-network dentist takes on the responsibility of filing all bills, claims, and paperwork, you as the patient are relieved of those headaches.
Many patients and dentists like to get a pre-treatment estimate from insurance companies prior to starting expensive, complex dental procedures. In-network dentists have this process in place and can easily provide all necessary X-rays, test results, and paperwork. An out-of-network office may not be willing to provide this service for you and most patients are ill-prepared to complete this complicated process.
Dentists who contract with insurance companies undergo a process known as credentialing. This means representatives of the company have verified the dentist’s licenses, specialty certifications, malpractice insurance, and status with state regulatory boards. This can assure you that the dentist meets strict standards and is in good standing with the professional community.
This is a process by which insurance companies monitor the treatment patterns of their in-network dentists. This process helps the company evaluate the dentist for practicing within the acceptable standard of care found in other dental practices in the community. Using an in-network dentist can give you confidence that the in-network dentist is not over-treating or under-treating, using unproven treatments, or performing services outside the norms of standard dental practice. If, for example, a dentist is billing the insurance company for an extraordinary number of crowns, far more than other dentists in the area, the insurance company may investigate and, if it is found that the dentist is over-treating, they may be dropped from the plan’s list of providers. There are no such protections for the patients of out-of-network providers.
Usual and customary fees
Insurance companies determine the fees that are reasonable for that service in your community. They constantly compare claims filed and keep a database of dental services and the normal fees associated with that service in various geographic areas. This helps the insurance company keep track and update their allowed charges for a variety of dental services. Their allowed charge is the amount a company will pay for a dental service. For in-network dentists, this charge is based on their contract. Out-of-network dentists are not bound by allowable charge limitations. To ensure you are not charged more than is usual and customary for your area, use an in-network dentist whenever possible.
The downside of using in-network dentists can be fewer options in some areas but that varies depending on the size of your network and your location.
What happens if I go to an out of network dentist?
Some people opt to use an out-of-network dentist due to an urgent need for care or because their trusted dentist is not a member of their plan’s network.
Because out-of-network dentist have not signed a contract to provide care to plan members at a discounted rate, you will pay more for services. Increased fees might not be enough to cause you to switch dentists, but if the cost is your top priority, stick with a dentist who participates in your insurance plan’s network.
Occasionally, your in-network dentist may need to refer you to a specialist for complex care, such as oral surgery, implants, braces, or root canals. When this happens, ask if there is an in-network specialist who can provide your treatment.
Some out-of-network dentists will file claims on your behalf, depending on the type of insurance you have. Most will file claims for you if you have traditional dental insurance or a DPPO. However, out-of-network dentists do not have a relationship with the insurance provider or a representative of the company to reach out to when questions arise or to assist with claim denials. Many out-of-network dental offices will file your claims, but that does not mean you will get any of the discounted rates that in-network dentists offer. If you have a DHMO, you will probably have to pay in full at the time of service at out-of-network dental offices.
How to find a dentist in my network
Most dental insurance companies provide easy access to lists of dentists in your area who are members of their network. You can usually find these on company websites or in written materials sent to you annually from the insurance company.
Choosing a dentist can be stressful. Do you want someone young, fresh out of dental school with knowledge of the latest techniques and technology? Or do you want a dentist who is more seasoned and experienced? Do you want to go to a large clinic with several dental providers who can accommodate a non-traditional schedule and always has a dentist on call for emergencies? Or do you prefer a small, one-dentist office where you can build a more personal relationship with the dentist and her staff?
Word of mouth and recommendations from friends and family members can be a good place to start. Armed with a list of characteristics of your ideal dentist and advice from coworkers and neighbors, your next step to finding a dentist in your network is to access the list of dental providers on your insurance company’s website.
Once you have selected a network dentist, call the office to confirm that they are still under contract with the insurance company. Sometimes, contracts expire, and websites are not always up to date. It will save confusion and stress to verify that the dentist is still participating in the plan before you make an appointment.
Using an in-network dentist is usually the wisest choice. Take the time to investigate the network providers and see if you can find one that best suits the needs of you and your family.
Brought to you by The Guardian Life Insurance Company of America (Guardian), New York, NY. Material discussed is meant for general illustration and/or informational purposes only and it is not to be construed as tax, legal, investment or medical advice. This is not dental care advice and should not be substituted for regular consultation with your dentist. If you have any concerns about your dental health, please contact your dentist's office.