In Network or Out of Network, and What It Costs You

If a dentist is in network with your plan, the office has already agreed to charge a set fee for each procedure, and your share is worked out from that discounted number. If the office is out of network, it charges its own fee, your plan pays against its own allowance, and the gap between the two can end up on your bill.

That gap is usually the entire reason two offices quote different amounts for the same crown. Here is how each arrangement works, what balance billing means in practice, and what to check in one phone call before you book.

In network means the office agreed a discount before you walked in

An in network dentist has signed a contract with your insurance company. That contract includes a fee schedule: a list of procedures with the maximum the office may charge a member of that plan. The office cannot bill you above that figure for a covered procedure, even if its usual fee is higher.

So when your plan says it covers eighty percent of a filling, the eighty percent is calculated from the contracted fee, not the office's regular price. Your coinsurance is the remaining share of that same lower number. This is why in network care is generally cheaper and easier to predict, and why plans push you toward it.

Out of network is not the same as not covered

People often hear out of network and assume they will pay everything. With most PPO plans that is not true. The plan still pays, but it pays a percentage of what it considers a reasonable fee for your area, sometimes called the allowed amount or the usual and customary rate.

The catch is that the office never agreed to that number. If its fee is higher, nothing stops it from charging the difference. A plan that pays fifty percent out of network against an allowance well below the office's fee can leave you covering considerably more than half. With a DHMO or a plan with no out of network benefit at all, going outside the network usually does mean paying the full fee yourself.

Balance billing is where the surprise usually comes from

Balance billing is the office charging you the difference between its fee and what your plan allowed. It is normal and legal for an out of network dental office, and it is the line item that catches people out, because it appears weeks later on an explanation of benefits rather than at the front desk.

You can see it coming if you ask for the numbers up front. Any office can tell you its fee for a procedure code, and your insurer can tell you the allowed amount for that same code in your ZIP code. The difference between those two figures is roughly what a balance bill would be.

• Ask the office for its fee by procedure code, not a rough verbal figure
• Ask your insurer what it allows for that code in your area
• Ask whether the office will submit the claim for you or expect payment up front
• Ask for a pre treatment estimate in writing for anything over a few hundred dollars

The percentages in your plan booklet are only part of the math

Coverage levels are usually written as something like one hundred percent for cleanings and exams, eighty percent for fillings, fifty percent for crowns, bridges and dentures. Those percentages apply after your deductible and only up to your annual maximum, which on many employer plans falls somewhere between one thousand and two thousand dollars a year. Amounts vary widely by employer, by plan and by state.

Waiting periods matter too. Many plans make you wait several months to a year before they will pay toward crowns or other major work. A treatment plan can be perfectly affordable on paper and still leave you short once the deductible, the waiting period and the annual cap are applied to it.

One phone call answers most of it

Call the office and ask whether it is in network with your specific plan, not just with your insurance company. Large carriers run several networks, and an office can participate in one and not another, so the name on your card is not enough. Then call the number on that card and confirm the same thing from the insurer's side.

If you are starting from scratch and want to see which practices are even near you before you begin calling, the directory searches every dental practice in the United States by town or ZIP code and shows the closest first, free and with no account. Once you have a short list, the network question takes about five minutes per office.

• Give the office your exact plan name and group number, not just the carrier
• Confirm the same answer with your insurer before a large treatment starts
• Check whether the dentist you were assigned is the one who will treat you
• Re check every January, since networks change with the plan year

Sometimes out of network is still the right call

Network status is a billing arrangement, not a rating. Plenty of good dentists stay out of network, and a dentist who already knows your mouth, or a specialist with real experience of the exact problem you have, can be worth paying more to see. For complex work, the cost of doing it twice tends to dwarf the difference in a fee schedule.

The point is to choose it knowingly. Get the fee, get the allowed amount, get the estimate in writing, and decide with the real number in front of you rather than finding it out after the work is done.

Frequently asked

This is general information to help you ask better questions, not a diagnosis. Anything happening in your own mouth needs a dentist who can look at it.