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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 know 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 provider network for the dental plan. 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."

An insurance company may have multiple dentist networks. For example, one network may be used for PPO dental plans and another may be used 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 dentists who do accept PPO insurance, the average participates in 26.5 different networks according to statistics from the National Association of Dental Plans.

Why Out-of-Network Matters

Depending on the dental plan, the use of an out-of-network dentist may have different consequences. Within a PPO dental plan, out-of-network dental care may result in higher out-of-pocket costs. A HMO plan, in contrast, 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.

Aside from financial considerations, there is the matter of dentist choice. Quality dental work comes from dentists, not insurance. Consequently, a dental insurance plan 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.

Should You Use 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: