Whether you’re currently enrolled in a dental plan or shopping for one, it’s important (and financially beneficial) to understand the concept of “staying in-network.” Visiting an in-network provider can benefit you in three ways: lower out-of-pocket expenses, no extra charges, and no paperwork for claims.

For example, let’s say “Jill” is looking for a dental plan and she finds two of the most common types, PPO and Fee Schedule:

  • PPO Network: With a dental PPO plan, she has access to a network of providers who have agreed to accept negotiated, discounted rates for their services, often 10% to 15% or more below the usual and customary fees charged by dentists in the same market. This plan also allows her to visit out-of-network dentists, if she chooses, but these dentists have not agreed to accept the discounted network rates.
  • Fee Schedule: These plans pay for covered services based on a set reimbursement amount per procedure. This plan allows Jill to visit any dentist she chooses. In-network dentists may still agree to charge the network’s negotiated rates, but the plan will only reimburse them up to the amount specified.

So, how can Jill save money by staying in-network for either plan?

Jill will need to check if her current dentist is in the dental plan carrier’s network and then evaluate the benefits and costs of staying with that dentist if he or she is not in-network. Let’s take a closer look.

If Jill sees an in-network provider in a PPO plan:

  • Lower starting costs – Jill will pay less for services or procedures, due to negotiated rates with in-network providers.
  • No hidden charges – Jill is responsible only for her deductible and/or co-insurance.
  • No balance billing – Jill will not pay charges that exceed negotiated rates for services provided by an in-network provider.
  • No paperwork – In-network dentist offices file all claims for Jill.

 

If Jill sees an out-of-network provider in a PPO plan:

  • The cost of Jill’s services (billed charges) are based on the dentist’s standard fees, not on network-negotiated rates.
  • Jill is responsible for her deductible and co-insurance, however, the plan’s part of the co-insurance is based on the network-negotiated rates.
  • Jill will be billed for any remaining amount up to the billed charges.
  • Jill may need to file claims herself.

 

If Jill sees an in-network provider in a Fee Schedule Plan:

  • Lower starting costs – Jill will pay less for services or procedures, due to negotiated rates with in-network providers.
  • No hidden charges – Jill is responsible only for her deductible and the remainder of the provider’s negotiated rate not covered by the plan’s scheduled fee payment.
  • No balance billing – Jill will not pay charges that exceed negotiated rates for services provided by an in-network provider.
  • No paperwork – In-network dentist offices file all claims for Jill.

 

If Jill sees an out-of-network provider in a Fee Schedule plan:

  • The cost of Jill’s services (billed charges) are based on the dentist’s standard fees, not on network-negotiated rates.
  • Jill is responsible for the cost difference between the dentist’s rate and the plan’s scheduled amount.
  • Jill may need to file claims herself.

 

No matter which plan Jill decides to enroll in, she will maximize her savings by using one of the carrier’s in-network providers due to the negotiated rates. You can view a provider network as a “savings club” for members. Going out-of-network would usually mean Jill would have to pay a larger percentage of the cost of service, or the total cost of service altogether.

Learn more on how to chose the best dental plan for you in our article, “Buying Dental Insurance – Which Plan is Right for You?