Congratulations! You signed up for dental insurance and you are anxious to finally go to the dentist! How important is it to find a provider who is in-network with your specific plan? There are financial advantages to seeking an in-network dentist, but there some factors you should take into consideration before making a final decision.
1. Which type of plan did you purchase?
There are few types of plans, but most people have one of two types: a plan that allows you to go to any doctor, or a plan that assigns you to a specific doctor.
If your dental plan assigns you a specific dentist, that plan is typically called an HMO or a DHMO. These plans are cheaper to purchase but unfortunately lock you into whichever dentist they assign to you. Before you decide to go with the budget option consider this: these plans pay providers very little so the dentists who take these plans may not be able to afford the latest technology and they also will need to see a lot more patients to keep their practice in the black. These factors may impact your experience.
There are different acronyms used for plans that allow you to see any dentist you chose, but PPO is the most common and though they have providers they “prefer” (which is why it’s called a “Preferred Provider Organization”), they will pay a claim, regardless of which dentist you choose to see. It is important to understand that your insurance company prefers dentists who have a contract with them. In a nutshell, the contract states that the insurance company will advertise the dentist on their network, and in exchange, the dentist agrees to take reduced fees for in-network patients. Clinical skill, convenient appointments, amenities, and other factors are not usually a consideration when a dental insurance is “preferring” a certain doctor. Read reviews. Do your research!
Keep in mind that if you have a PPO plan and are seeing an out-of-network provider, they should absolutely do all the paperwork for you so that you will receive reimbursement. Sometimes you will need to pay the office fees upfront and receive reimbursement directly from your dental insurance. Sometimes they will estimate what they think your insurance will pay and take a reduced rate up front, with the understanding that you will be responsible for any remaining balance.
2. Do you already have a dental home where you are happy?
If you have not been to the dentist in years, it makes good sense to find a provider who is in your network. But let’s say you’ve been seeing the same dentist for years and you get a job that offers dental benefits. Awesome news! You can finally stop paying so much at the dentist. You happily sign up, get your card, and then call your dentist with the great news that you are the proud owner of a shiny new dental plan. Then you find out from the receptionist that they are not contracted with the plan your employer chose for you. What should you do?
You can look for a new dental home, and many people choose that route. However, if you have a long-standing relationship with your dentist and his team, and they have built trust with you, consider staying on board. Unfortunately, not all dentists possess the same clinical skill, chair side manner, or employ well-trained staff who genuinely care about their patients. If you have found someone who makes you feel comfortable and you enjoy your visits (as much as you can enjoy a visit to the dentist!), you may save some money moving to an in-network dentist, but you risk being disappointed by your experience. And remember, they will still file the claim for you, and you will receive reimbursement from your dental plan.
3. How much money does your plan reimburse for out-of-network dental visits?
This is a much longer and more complicated discussion that involves deductibles, co-pays, categories, plan maximums, and your specific treatment plan. But there is a very simple question you can ask your dental insurance carrier before deciding to see an out-of-network general dentist for your everyday oral health maintenance and basic dental needs: Does my plan reimburse at the ‘usual and customary rate’ or does it reimburse based on a fee schedule?” Usual and customary, or UCR, means that they typically reimburse more money, oftentimes up to the amount your dentist charges. A fee schedule means that they will only pay a certain amount, regardless of the actual charge. So, if your dentist charges $100 for a basic hygiene cleaning, the UCR reimbursement may very well cover the entire $100 and you would get 100% reimbursement. But a fee schedule may have a set price of $50, regardless of the market rate for hygiene visits in your area. You may have been told your plan would cover 100% of your cleaning, but if the plan pays on a fee schedule, it could mean it pays 100% of $50, leaving you with a surprise $50 bill.
This misunderstanding has caused many angry one-star reviews for dental offices. I work to train front desk financial coordinators to be fully transparent and educate patients to avoid unwanted surprises, but not every dental office has fully trained staff. The more educated you can be as a consumer, the better experience you will have. If you understand upfront that you may be billed for any amount not covered by your plan, you can make an informed decision and ultimately have a much better experience.
To recap, before you decide to go to an out-of-network dentist, call your dental insurance provider and ask the representative if your plan pays UCR or on a fee schedule. Bonus Tip: If they pay on a fee schedule, ask your employer if you can get a copy of the fee schedule. Armed this way, you can ask your dentist their fees and know before you go in how much you will have to pay!
4. Do you need to see a specialist?
Sometimes you have a dental issue that is outside the scope of your general dentist’s expertise. Specialists are dentists who have extra years of education focused on their chosen area of study. For instance, endodontists are specialists who do root canals and related surgeries on the roots of teeth. Your general dentist may perform root canals, but if the anatomy of your roots are unusual, they may refer you to a specialist for a consultation in the hopes of a better outcome for you. Depending on your location, there may not be many specialists who are contracted with any plans. In this case, be prepared to pay a portion out of pocket, regardless of your dental plan. You will still receive reimbursement if you have a PPO, but most dental plans have a maximum amount they will pay each year. When your dental needs require a specialist, you will likely meet that maximum quickly.
5. Are financial considerations your primary concern?
There is an adage that you can choose two out of three: good, cheap, or fast. This is especially true at the dentist. If you find an in-network dentist who provides excellent care, you will probably have to wait for your appointment. If your dental home always has openings and costs less, you have probably found an office with a lot of different dentists and you might not see the same one twice. If you want to see the same dentist who will spend time with you and has the experience to offer superior clinical care, then you can expect to pay a little more. If you do not already have a dental home, look at the providers on your in-network list and then read reviews online. If you find a dentist who has amazing reviews, that’s great news! Don’t be upset though, if you must wait for your appointment. Decide what is most important to you and then set your expectations appropriately. You will feel better about your experience and enjoy a good relationship with your dentist and the team.
In conclusion, it’s always financially wise to research your in-network dental options, but if you have a PPO plan, do not be completely close-minded to seeing an out-of-network provider. Ask specific questions in order to make the most informed decision for yourself. To increase your chances of choosing the best dentist for yourself, keep these five factors in mind, then ask your friends for their recommendations and read reviews online!
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