Dentist Sewell NJ | Cometic Dentistry | Connolly Family Dentistry

In-Network versus Out-of-Network…What does it all mean?

When choosing a dental healthcare provider, a lot of factors go into your decision-making: Where did the dentist train?  Does he/she have a good reputation?  Is the office close to my home?  And, last but not least, do they take my dental insurance?

We have been conditioned by insurance companies to believe that we can only see clinicians that participate with our insurance, otherwise known as “in-network providers.”  But what does that really mean?  This article will give you a brief, no-nonsense explanation of the difference between in-network and out-of-network dental providers using everyday language that people can actually understand!  It is much simpler than we think!

In-network dentists agree to terms and conditions set forth by insurance companies.  The insurance company can actually decide what types of procedures the in-network dentist can do for patients covered under their plan.  The insurance company can deny payment or require the dentist to downgrade the treatment he/she has diagnosed for the patient because the insurance company deems it cosmetic or unnecessary (even if the dentist believes it is the best line of treatment and will result in the best outcome).  In addition, in-network providers agree to fees for their services set forth by the insurance company.  They agree to take whatever payment the insurance company is willing to provide.  Most often, this insurance “reimbursement” is far less than the value of the procedure, clinician’s time, and materials used.  Because of this, in-network providers tend to see more patients in the same amount of time as out-of-network providers, to make up for the difference between the actual value of the procedure and what the insurance company will pay.

Out-of-network dentists refuse to allow insurance companies to dictate how they will treat their patients.  They choose not to sign up with insurance companies because they do not want the restrictions that in-network dentists must conform to.  Out-of-network dentists are free to do what is best for the patient.  They diagnose and treat with only the patient’s best interest in mind.  They don’t have to stop and think, “oh, but will their insurance agree to this?”  They are unencumbered by the stipulations set forth by insurance companies.  Therefore, out-of-network dentists are able to use the best materials and techniques, ensure the best cosmetic outcome (it is your smile, after all!), and spend much more time with their patients.  Only you, the patient, and your dentist, know the issues you have, the sensitivity you may be feeling, and the look you want to achieve, so only you and your dentist know what line of treatment is best for you.  Out-of-network clinicians provide a one-of-a-kind experience.  In-network providers tend to lean toward more of a cookie-cutter, one-size-fits all experience for their patients, because that is least time consuming and cheapest for the insurance company.  This doesn’t mean that in-network dentists are subpar, it just means that they have to answer to the insurance company and follow their rules.  Out-of-network dentists do not.

Most consumers believe that if you see an in-network dentist, that you will pay nothing for your appointments.  This is just not true!  Every insurance plan has tons of rules or stipulations for their coverage.  For example, some work on a fee schedule meaning that they will pay only a percentage of a service.  Others provide annual benefits, meaning that they give you a set maximum amount that they will pay toward your dental care in one year.  Some only provide coverage for preventative appointments, and most all have deductibles that have to be met before the insurance company will pay.  Always read the fine print and ask questions before signing up for dental insurance so you can be prepared for what they will actually cover.

In addition, insurance companies use scare tactics to train consumers that out-of-network providers are “bad” and more expensive.  Their websites use language like, “beware of out-of-network providers,” and “avoid paying high out of pocket costs.”  They don’t explain that even with insurance, you will still have out of pocket costs, or that your treatment could be downgraded or even denied by your insurance company.

So, does this mean that you will pay more for an out-of-network provider?  You might.  It all depends on your insurance plan, the treatment you need, and the stipulations set forth by the insurance company about what services they will cover and when they will cover them.  Usually, for preventative appointments, like cleanings and exams, there may be an out-of-pocket expense when visiting an out-of-network provider.  However, it is usually not a large amount, contrary to insurance company rhetoric, and it is worth the price for the increase in time and the quality of care provided.

So, what’s the bottom line?  As always, you need to do what is best for you and your health.  It is comforting to know, however, that you can see whichever dental practitioner you choose, and that you are NOT required to see only those within your insurance company’s network.  You can’t go wrong if you choose a practice where you feel comfortable and cared for, regardless of whether they are in-network or out-of-network.



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