Do I Have to See an In-Network Dentist?

Do I Have to See an In-Network Dentist?

By: Dr. Greg Grobmyer

Many people think that they can only see a dentist if the dentist is in their insurance network. Seeing an in-network provider has its advantages, but out-of-network providers are an option as well. Often, they may even be the better choice!

What does it mean to be “in-network?”

There are several different kinds of dental insurance plans. Some, like HMOs, or Health Maintenance Organizations, require that a patient can ONLY see the dentist they have been assigned. These plans are usually less expensive but very limiting in who you see and what services are covered.

Another, more flexible, type of insurance is called a PPO, or Preferred Provider Organization. Most companies that offer dental insurance provide a PPO plan as an option. In a PPO, patients are provided with a list of “preferred” dentists who have opted to offer their services at a reduced rate. These dentists are considered “in-network.”

What are the pros and cons of staying in-network?

The primary reason for staying in-network is cost. As mentioned, in-network dentists have agreed to take a reduction in their fees in order to be on the list of preferred providers. It’s essentially a way for them to market themselves to potential patients. They hope to make up for the lower fees by seeing more patients.

In-network dentists have to charge based on a fee schedule set by the insurance company. These plans will allow prices to be set up to a certain amount — known as UCR, or “usual, customary, and reasonable.” The overall price that dentists can charge for a procedure is capped, which usually means lower costs to the patients.

Unfortunately, what insurance companies call “usual, customary, and reasonable” may not be enough to actually cover the costs of providing the best care for the patient. Participating dentists are not allowed to charge you the difference from their usual rates. As a result, they may have to reduce costs in other ways to remain profitable, like using less expensive materials.

What about using an out-of-network dentist?

It may come as a surprise to many, but out-of-network dentists are still able to file your PPO insurance. In most cases, the insurance will still pay their percentage up to the coverage cap they have set, but no more. The dentist is not constrained by the fee schedule, so the final cost to the patient may be higher.

While this sounds like a big deal, the difference in price is often minimal. It may be just a few dollars to have a cleaning instead of it being fully covered. Fillings may be $10-$15 more expensive after insurance. Or there may even be no difference at all! It depends on the insurance, the dentist, and the procedure needed.

Out-of-network offices also are not limited in what kind of services they may offer. They will be able to provide optimal care using higher-quality materials and techniques, but the cost will likely be higher. Higher-quality work tends to last longer and work better, however, so you might end up saving money in the long run.

Ultimately, the choice is yours.

Both in-network and out-of-network providers are able to take care of your dental concerns and file your PPO insurance for reimbursement. They will both be able to receive insurance payments up to a certain amount, but the in-network provider is not allowed to charge any more than that cap.

Because of this arrangement, in-network dental offices will usually be less expensive, but occasionally the quality of work may be lower. You are also required to choose a dentist on their list to receive the reduced rates.

Out-of-network dentists are not held to a capped fee schedule, so their prices will likely be higher. Because they are able to charge more, however, they are more likely to use higher-quality materials and techniques. These may not be covered the same way as at an in-network provider. The difference in final price may be nothing, some, or large.

When looking for a new dentist, ask if they are in-network or out-of-network for your insurance. Check and see if they will still file your insurance if they are out-of-network and ask what price differences to expect for exams and cleanings.

Finally, don’t just rely on insurance to decide who you see for dental care. Pick an office you like and somewhere you feel well taken care of. That is worth more than any insurance can cover!

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