When it comes todental insurance, the terms "in-network" and"out-of-network" refer to whether a dentist or dental care provider has a contract with your insurance company. Although sometimes confusing, knowing the difference is important for understanding how your insurance will pay in these scenarios and avoiding any surprises.

In-Network Dentist

Contracted Rates: An in-network dentist has an agreement with your insurance company to provide services at pre-negotiated, discounted rates. These rates are typically lower than what the dentist would charge without the insurance contract. In return, the dental office hopes to receive more of aninflux of patient referrals from the insurance company.

CoverageBenefits: Choosing an in-network dentist usually means that your insurance plan will cover a higher percentage of the cost, and you may have lower out-of-pocket expenses.

Example: Dental office normally charges $95 for an exam, however with a specific plan, they’ve opted to be “in-network” and accept $60 for subscribers of this plan. If the plan covers exams at 100%, then the insurance will pay the dental clinic$60, and the patient will owe nothing. However, if the plan pays less than that amount (maybe insurance is charging a deductible, patient has reached their annual maximum, or the plan only covers exams at 80%) then the patient will owe the remainder, such that the clinic receives a total of $60 between the insurance and patient.  

Out-of-Network Dentist

Non-Contracted Rates: An out-of-network dentist does not have a pre-established agreement with your insurance company. As a result, they are not bound by the insurer's negotiated rates. However, almost all insurance plans will still pay for services from an out-of-network provider. Sometimes even at 100%!

Potentially Higher Costs: Since there's no predetermined rate, your portion will be based on the dentist’s regular fees, minus what your insurance contributes. Often times insurance companies will list a percentage they will cover for services provided by an out-of-network provider. However, these percentages are generally based off a maximum fee for each service, above which the patient may be responsible for.

Example 1 –Office’s normal fee for an exam is $95. Insurance plan states that they cover 100% for exams, even for out-of-network. This plan has a maximum allowed fee of$100 for exams. Therefore, they will pay for the entire exam ($95) and the patient will owe nothing.

Example 2- Office’s normal fee for an exam is $95. Insurance plan states that they cover 100% for exams, even with out-of-network providers. However, not readily disclosed is that their maximum allowable fee for an exam is $70. This means that they will cover 100% up to $70, and the remaining $25 will be owed by the patient.

Before scheduling dental services, it's advisable to check with your insurance provider to understand your plan's network, coverage details, and any potential out-of-pocket expenses.

At Wallingford Dental Care, we are happy to disclose our office fees. If we are out of network with your plan, you may be able to ask your insurance company what their maximum allowable fees are for each of the services in order to be able to better estimate your left over portion. In some cases, we may be able to submit a pre-authorization to your insurance to get an estimate of what they may cover for a procedure.

Read our next post to learn about why some dental offices are out-of-network, or are going out-of-network with certain plans.