In-network providers, also referred to as participating providers, are those who contract with insurance companies and provide services at pre-negotiated rates. Out-of-network providers are simply those who do not contract with an insurance company. Note that some providers contract with some insurance companies, but not necessarily all.
People may opt to see an out-of-network dentist because it’s someone they have a long-term relationship with and/or their preferred dentist just doesn’t participate. Most dental plans will allow you to see whichever dentist you’d like and will pay on an out-of-network basis. The risk these folks run, though, is that since there is no contract, the provider might bill at a higher rate than the insurance company is willing to pay, leaving the member potentially exposed.
Many dental plans will pay out-of-network dentists at what’s called a “usual, customary, and reasonable” level, also known as UCR. This means the insurance company will pay the provider based on the geographic area of the dentist and on the service performed. As an example, a service performed in Fairfield County is likely going to cost more than a service performed in Litchfield County. With UCR, the insurance company is adjusting for that.
The most common UCR we see is the 90th percentile. This means that what the insurance company pays an out-of-network provider should suffice for 9 out of 10 dentists in that geographic area for that service. This also means that the payment may not be sufficient for 1 out of 10 dentists in that geographic area for that service.
Here’s an example:
You go to a local dentist for a periodic oral exam and routine cleaning, both of which are considered preventive services covered at 100% under your plan. The billed amount by the provider is $200.
If the dentist is in-network, they’ll bill at $200, but their contract might say that a periodic oral exam and routine cleaning will be paid at $150. Even though there’s a $50 difference between what was billed and what was paid, the dentist cannot bill the member because of the contract.
For conversation’s sake, let’s say that the insurance company determines that based on where this dentist practices, a periodic oral exam and routine cleaning performed on an out-of-network basis will be paid at $190. In our example, the dentist bills at $200 and gets paid $190.
The insurance company’s statistics show that 9 out of 10 dentists will accept the $190 paid out-of-network and that 1 out of 10 dentists will not. To an extent, if you’re lucky, you won’t be balance-billed the $10 difference. If you aren’t lucky, expect the bill for $10. Remember, since there is no contract, the dentist can bill you the difference.
Network Status | Billed Amount | Allowed Amount | You Owe |
In-Network | $200 | $150 | $0 |
Out-of-Network | $200 | $190 | Possibly $10 |
If your regular dentist is out-of-network, it might not be the end of the world. But if you need extensive work performed, you may want to be in-network, as the difference between what’s billed and paid could be substantially different in contrast to the example provided above.
Never hesitate to ask for a listing of in-network providers or to confirm that the provider you’d like to see participates. It could keep more money in your wallet at the end of the day. Also know that if your provider is out-of-network and refuses to submit the claim to your insurance company on your behalf, we’re here to help.