Understanding Your Dental Insurance: In Network vs. Out of Network

Did you know that just because your insurance is considered out-of-network doesn’t mean you have to give up quality care? Dental insurance can be very confusing, even for those of us who work in the dental field, and we receive a lot of questions from parents about in-network and out-of-network benefits and what it means if they don’t have dental insurance. So this week, Amy Morgan clears up the confusion surrounding dental insurance and explains how it differs from health insurance!

For starters, let’s define in-network and out-of-network. In-network benefits means that your dental insurance provider has a contract with PDAO and is offering slight discounts or slight fee adjustments in order for you to pay less out-of-pocket costs after appointments. This does not always mean that you will receive a large discount, it simply means that we have a contract with them and have quoted our fee and they have agreed to pay a portion of that fee, depending on what they consider a customary price, which we will then adjust off of your treatment cost as an insurance adjustment.

On the other hand, out-of-network means that we do not have a contracted fee with a dental insurance provider. This means that a specific provider did not offer a list of fees that met an appropriate threshold for our practice, therefore we did not contractually agree to be a part of their in-network provider group. This does not mean that we cannot or will not file your insurance, and it doesn’t mean that you will have a large out-of-pocket cost. It just means that we will not discount the fee, but the insurance provider may still cover some of the cost.

Dental insurance is different from health insurance in that dental insurance works on fee schedules in conjunction with in-network and out-of-network benefits. For health insurance, the cost of services in-network versus out-of-network could end up being a big difference in cost, however for dental insurance, fee schedules determine cost based on an agreed upon contract between the dental office and insurance provider. 

If you don’t fall under the in-network or out-of-network category, then you may fall under the self-pay category. This means that you could not have dental insurance or that you’re covered by dental insurance under your medical plan. If this is the case, either you’ll pay a flat fee and that’s it, or if you do have insurance, you will pay the full cost of the appointment and then file it with your insurance on the back end.

We do offer discounts if you are paying in full as long as you are also receiving orthodontic treatment. However, based on our contracts with insurance companies and the state of Arkansas, we cannot offer discounts for regular dental procedures like cleaning, fluoride treatments, etc. because we are ethically required to treat every patient the same.

At PDAO, we have dedicated insurance coordinators in both of our locations that are working daily on patient insurance. We strive to provide the most accurate information that we can, and we try to get our estimates as close to what it should be on every single visit. As far as the information that we have to gather to be able to run your insurance and check your benefits, we require you to schedule an appointment in order for us to gather all your insurance information before we are able to further investigate what your benefits are.

No matter what, we want to educate you on your insurance benefits and let you know that if you are wanting PDAO to be your provider that insurance DOES NOT have to be a barrier for that!

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