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Dental Insurance, In or Out of Network?

As a dentist in current times, the first question I'm asked when I meet someone out and about who learns that I'm a dentist is, "Do you take MetLife (insert your carrier here)?", "Are you in my plan?" The answer is never a quick yes or no, however, and it's important for patients with insurance to understand their coverage.

First of all, these days most people who have dental benefits/insurance have what is known as a PPO (preferred provider organization) which means the carrier has dentists who have signed contracts with the carrier agreeing to accept the fees outlined in the specific plan basically in exchange for referrals of patients. The term by no means implies that the dentists is the plan have special, better or different skills or credentials than any other dentist. They are simply "preferred" because they agreed to accept lower fees as a provider in that network.

Does this mean if you have a PPO you can't go to a doctor who is not in the plan? Absolutely NOT! The implication is that if you go outside of your network, it's going to cost you a bunch of money from your own pocket for your treatment. This simply isn't true. In my own experience, most of my PPO patients' policies pay for all or most of the fees for preventive care, and I am not in any network. The only time there's a large difference in the fees is when the plan fees are ridiculously low. For instance; in an area where the average fee for a crown is $1200, if the plan has a set fee of $750, and it's covered at 50%, the benefits paid would be $375 of the $1200. This is $225 less than a non-PPO plan would pay. The PPO patient would then have an out-of-pocket expense of 225+600, or $825 versus $600 with a traditional plan. The decision of whether the $225 difference is worth it is obviously up to each individual patient, but they should keep in mind that if the usual fee for a crown in their area is $1200, and the doctor is contracted to accept $750, something's go to give. The quality of materials, the number of patients the doctor is running between, the amount of time you are in the office, the skill and training of the staff, the quality of the dental lab and the materials used are all places where corners can be cut to save money and make up for the difference in the fee.

On the whole, however, you will find that your out of pocket costs will be less than you might assume, and certainly not enough for you to use that as your criteria for who you choose to be your dentist. That is a highly personal relationship, and you have to be where you have confidence in your doctor so you can form a long term doctor patient relationship and not jump from office to office every time your plan changes or the dentist you were seeing drops the plan because their fees are too low.


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  • This brings up a very good point about PPO insurances. Our office actually offers its own membership prices for those that do not have the cost benefits of dental insurance. Granted, if a patient does carry dental insurance but the negotiated fee is a lot lower then the patient paying a slightly higher deductible may be worth it if quality is of priority. This is not to say that fees dictate quality always but it may be something to look into for the reasoning of higher fees compared to what is offered for fee coverage.

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