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Out-of-Network Dentists

By Insurance Industry Expert & Author
Updated on

What Is an Out-of-Network Dentist & How Can One Affect Your Wallet?

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 why it matters if a dentist is in-network or out-of-network for a particular dental plan. 

Why Networks?

An insurance company contracts with individual dentists with the interest of securing lower rates for treatments in exchange for the patient volume the insurance company can provide to the dental practice. The collection of these contracted dentists is the network for the dental plan. Sometimes this network is called the provider network. Any dentist not belonging to the provider network is considered "out-of-network." Conversely, those dentists in the contractual relationship with the dental plan are considered "in-network."

A single insurance company may have multiple dentist networks. For example, an insurance company may use one network for PPO dental plans and another for HMO dental plans. HMO networks are often smaller than PPO networks. It is also common for a single dental practice to belong to multiple dental networks. However, 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).

Out-of-Network Dentist PPO

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.

Out-of-Network Dentist HMO

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 a 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.

Can I Go to an Out-of-Network Dentist?

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:

  • Is there a different in-network dentist whose quality and location is acceptable?
  • How much more money will dental care cost if an out-of-network dentist is used?
  • Can I reasonably limit my use of an out-of-network dentist to major care?
  • Is there a different dental plan available in the area that contracts with the dentist who is out-of-network for the existing dental plan?

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.

Dental Insurance for 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.