Sometimes patients ask, “What does out-of-network mean in dental care?” You may save more money if you opt for in-network dental care, while an out-of-network dentist can be more expensive—but the financial difference may be much less than you think! As we like to say here at Ballantyne Endodontics, “out-of-network” doesn’t mean “out-of-service.” Understanding your dental insurance is important both for your budget and for your health. There may be times when an out-of-network dentist is your best option, especially if you need a specialist.

The big difference between an in-network and an out-of-network provider is that the in-network provider has a written agreement with your dental health plan. They may agree to specific rates and which services to offer you before they even see you as their patient. An out-of-network dentist isn’t beholden to your insurance network’s restrictions. The best choice for you depends on your needs, budget, the complexity of your condition, and the terms of your insurance plan.

If you opt to see an out-of-network provider, you will simply pass along your paperwork and invoice to your insurance company so that you will get reimbursed directly–instead of the provider getting reimbursed. There can be a cost difference to you between an in-network and out-of-network provider, but it’s often very small. We generally believe that you should choose the right and best provider for you and your dental needs, and not simply because they are within your insurance plan’s network.

Please note this article isn’t a substitute for medical, dental, or financial advice. We understand navigating these choices involves a combination of research, personalized professional advice, and weighing the pros and cons for yourself.

“Out-Of-Network” Varies by Your Dental Insurance Coverage

Some dental insurance coverage plans are called Health Managed Organizations (HMO) plans. This healthcare option tends to be more affordable overall since members are required to use the HMO’s own doctors, hospitals, and other professionals. If providers don’t work for the HMO, they are out-of-network. Whether a dentist is in-network or out-of-network depends on your specific plan. 

Some dental insurance plans are called Preferred Provider Organizations (PPO) plans, where there are specific participating providers to choose from. This gives patients more freedom and flexibility. It often works well when it comes to general dentistry, where you see the same dentist a couple of times a year for all your routine and preventative dental health needs. Depending on your city and dental health coverage, it only sometimes covers specialist care like oral surgeons, cosmetic dentistry, or endodontists.

A PPO plan usually offers more choice than an HMO since you are only limited to participating providers, not employees of the plan. Both models have their pros and cons. Understanding the limitations may help as you make decisions that impact your family’s oral health.

The upsides to an HMO include the following:

• Lower monthly premiums
• No deductible or a lower deductible
• Easier paperwork and easy to understand the terms

While HMOs can be cost-effective, the downsides may include:

• Limited choices, especially when it comes to specialists
• Need for a referral to receive specialist care
• Often no out-of-network coverage

A PPO offers more options but still has limitations. The pros include

• A more extensive network of health and dental care providers
• More choices, including specialists
• Possible partial coverage for services from out-of-network providers

The downsides include the following:

• Higher premiums and likely higher out-of-pocket costs
• Deductibles and caps on claims
• Often more difficult to figure out than an HMO

One important benefit to working with in-network dentists is that their office and billing staff are most likely familiar with your dental insurance plan’s coverage details. While this isn’t directly related to the care, it does make life easier for you.

On the other hand, one significant difference between in-network and out-of-network dentists is their willingness to accept limitations from insurance companies. In-network providers agree to the plan’s specific guidelines and restrictions, which means some of the decisions are made by administrators or the plan, not by a dental professional thinking specifically about your needs. They do this to manage the costs and risks.

An out-of-network dentist didn’t specifically agree to these terms and is less encumbered by the restrictions set by your insurance company. A dentist, including specialists like an endodontist, will ideally diagnose conditions and provide care based on their professional judgment and expertise rather than the cost of care. This can be more difficult for the dentist to do when they are bound by the terms of your insurance plan. This means that your insurance plan can sometimes influence your provider’s recommendations. 

Should I Consider an Out-of-Network Dentist?

Sometimes an in-network dentist is an ideal choice, but other times you may want to consider an out-of-network provider. This most obviously applies to services your dental plan doesn’t cover.

This varies by plan and may include anything from cosmetic dentistry to seeing the best specialist for your needs. For example, if your plan doesn’t cover an endodontist and you need a root canal, you may be faced with a difficult choice. You can go to your regular dentist for the procedure, where you will likely have at least some insurance coverage, or pay out-of-pocket to see a specialist endodontist. However, you can often submit your paperwork directly to your insurance for reimbursement, meaning it is not necessarily more expensive than an in-network provider. It all depends on what your plan covers.

The best choice is different for each person. However, when you consider that the average dentist only performs two root canals weekly, compared to the 25 root canals performed weekly by the average endodontist, it may be well worth it to seek care from a skilled specialist–especially in a complex case.

The cost of ongoing and persistent pain may outweigh the cost of specialized treatment when considering the quality of life, sick leave used, the price of pain medication, and lost opportunities to enjoy time with friends and loved ones.

Many out-of-network providers offer favorable low or no-interest payment plans to spread costs and make budgeting easier. Many PPO plans also provide partial coverage for out-of-network care.  Often, the added expense of seeing an out-of-network provider is well worth it when it comes to getting the dental care that meets your needs.

Contact the Provider You Hope to See

The best way to determine whether a provider is right for you is to contact their office and schedule a consultation appointment. Whether they are in-network or out-of-network, they will generally still be happy to see you for a consultation. It is essential to have this initial conversation with an out-of-network dentist’s office since your insurance plan may not cover the procedure or office visit. The front desk staff should be able to answer all of your questions about insurance, and once you’ve had your consultation appointment, they will be able to provide you with a treatment plan with estimated costs so that you can make the best decision for you.

If you are a Charlotte, NC, resident who needs a root canal or other endodontic care, you may be interested in seeing one of the specialists at Ballantyne Endodontics. We specialize in saving natural teeth, restoring wellness, and providing relief from pain. If you are in-network, out-of-network, or self-pay, we are very happy to treat you. Contact us today to learn about coverage options and schedule your appointment.