Dental plans often toss around terms like "in-network" and "out-of-network" as if every consumer works in the healthcare field and knows their meanings. In the interests of clarifying what is meant by the phrase "out-of-network" dentist, this article provides a brief overview of dental networks and then explains why it matters if a dentist is in-network or out-of-network for a particular dental plan.
What is a dentist network? A dental network is a group of dental professionals who all have agreed to provide services to an insurance plan’s members at rates predetermined by the insurance plan. An insurance company contracts with individual dentists to supply their dental plan enrollees with enough dentists to provide the care they need and in the regions where they live. The insurance company offers a dentist the prospect of increased patient volume from the company’s dental plan enrollees in exchange for the acceptance of the dental plan and the reimbursement rate the insurance company will pay for covered services. The collection of these contracted dentists is the dental plan network. Sometimes this network is called the provider network. Any dentist who does not participate in insurance plan's provider network is considered out-of-network. Conversely, those dentists who have a contractual relationship with the dental plan and participate in the provider network are considered in-network.
A single insurance company may have multiple dentist networks and limit network access by dental plan type. For example, an insurance company may use one network for PPO dental plans but another for HMO dental plans. HMO networks are often smaller than PPO networks. In some cases, there is also a tendency for less expensive dental plans offered by an insurance to belong to a smaller network and the more expensive plans to belong to the larger network.
It is common for a single dental practice to belong to many dental networks, though there are dentists who do not accept dental insurance at all. With respect to dental offices who do accept PPO insurance, the average participates in 26.5 different networks according to statistics from the National Association of Dental Plans.
The costs of using an out-of-network dentist is significantly determined by the type of network associated with your dental plan. The two most common dental network types are PPO (Preferred Provider Organizations) and HMO (Health Maintenance Organizations). In both cases, dental services outside the scope of the insurance plan’s benefits are uncovered. However, the cost implications of covered dental services received by out-of-network dentists is significantly different between PPO dental plans and HMO dental plans.
Depending on the dental plan, the use of an out-of-network dentist has different financial consequences. Within a PPO dental plan, out-of-network dental care is typically allowed but will result in higher out-of-pocket costs. The PPO model is typically better for dentists financially than HMOs and, as a result, PPO insurance acceptance is much more common among dentists than HMO acceptance.
A HMO plan, in contrast to a PPO plan, may not pay for any dental care provided by an out-of-network dentist, leaving 100 percent of the cost to the consumer. The same strict in-network restrictions apply to discount dental programs. In both cases, the plans are referred to as “closed panel plans” that do not permit out-of-network care.
Consumers are often confused when an HMO refuses to pay for out-of-network care because they do not understand how in-network HMO dentists are paid. Instead of getting paid by the insurance plan per dental service provided to a patient, a dentist operating in a HMO gets a monthly payment for every HMO customer who has the dentist assigned as their primary care provider. Because the HMO is paying pre-paying dentists per patient, out-of-network care is not accommodated by this business model.
As mentioned above, the use of an out-of-network dentist by an HMO plan enrollee can result in a surprise dental bill where the enrollee is responsible to pay 100 percent of the dental procedure cost with no financial assistance from the insurance plan.
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The decision to leave an in-network dentist in favor of an out-of-network dentist is not a simple issue. It involves answering questions such as:
With respect to this last question, there are several related matters:
Aside from the financial considerations of out-of-network dentistry, there is the matter of dentist choice. Quality dental work comes from dentists, not insurance. Consequently, dental insurance is only as good as the dentists who accept it. If a dental plan's local in-network dentists do not meet a consumer's standards for quality or customer service, it is reasonable for the plan's customers to consider out-of-network dentists.
Our agents can:
A dental emergency is an oral health issue where immediate treatment should be sought from a dentist or other qualified medical professional. Examples of dental emergencies include a broken or knocked out tooth. If you have a dental emergency, such as a tooth being knocked out of your mouth, you should make your oral health the priority and not a dentist’s network status. You can call your dental plan’s customer service number for guidance.
In the case of dental emergency where you do not have access to any in-network dentists, seek the appropriate dental and/or medical attention immediately. Remember that time is a critical issue with respect to dental emergencies. For example, it is recommended that a person who had a tooth knocked out see a dentist within 30 minutes of the tooth loss. The lost tooth should be handled carefully by the crown (and not the roots) placed in back in the socket where it was originally, if possible. If this is not possible, place the tooth in a container containing milk.
If affordability is a major concern, there are resources detailing low-cost dental care options.
Aside from the financial considerations of out-of-network dentistry, there is the matter of dentist choice. Quality dental work comes from dentists, not insurance. Consequently, dental insurance is only as good as the dentists who accept it. If a dental plan's local in-network dentists do not meet a consumer's standards for quality or customer service, it is reasonable for the plan's customers to consider out-of-network dentists.
The above information has provided a framework to understand out-of-network dental care from the perspective of PPO and HMO dental plans. If you live in a rural region where there are not robust networks of dentists, or if you just don’t like your dentist options among local PPOs and HMOs, you should consider an indemnity dental insurance plan.
An indemnity plan is a fee-for-service dental plan that reimburses a consumer for a portion of his or her covered dental expenses. The reimbursement amount is not dependent on what the dentist charges but, rather, the insurer's determination of "usual, customary and reasonable" dental fees. Inasmuch as this is an insurance company-specific definition, the reimbursements may or may not reflect the local cost of dental services. Depending on the indemnity plan, the patient or the patient's dentist may be required to submit a form to claim reimbursement. In contrast both to PPO and HMO dental insurance plans, indemnity plans normally operate without network restrictions for its enrollees, which permits them to choose the dentists of their preference.
If you are in immediate need of an out-of-network dentist due to quality or specialization concerns, the first step in finding one is asking friends and neighbors for recommendations based on their personal experiences. If you moved and are new to an area, you can also consider reading dentist reviews on websites such as:
As mentioned earlier, before scheduling care you should call the dentist's office and confirm the fees for the care you need in order to stay within budget. Ideally, you should compare fees among multiple dentists with similar reputations for quality dental work.
Sources:
Our knowledgeable customer service team will assist you with any questions you may have prior to enrolling in a dental plan. They can guide you through the process of choosing coverage that matches your needs as well as your budget.
