In-Network Vs. Out-Of-Network Coverage

As most of you have heard, Durango Dental is going out-of-network with the insurance Delta Dental as of 10/22/2022. This means that we will no longer be a preferred provider in the Delta Dental network. Many of our Delta-insured patients have asked us what it means to them, the patient, for us to be out of network. We want to address that question in this blog post.

What does it mean to be an in-network or “preferred” provider?

An in-network dentist is a dentist that has a contractual agreement with the insurance provider. The main thing that the contract addresses are the fees of the office. Either the insurance and dentist negotiate the fees together or the dentist is presented with a fee schedule and accepts or denies the fee schedule. For example, if a regular cleaning costs $100 in a dental office and the dentist is in-network, and the insurance company and the dentist have agreed upon an $80 fee for a cleaning, the dentist must write off $20 for every patient that comes in under that insurance. There are many different fees with insurances. Some pay as little as $45 for a cleaning and some pay the full fee of $100. If a dentist is in-network with multiple insurances, every patient pays a different fee, dictated by the insurance, for the same procedure.

What does it mean to be an out-of-network provider?

If a dentist is an out-of-network provider it means that the dentist does not have agreed prices with the insurance. So at an out-of-network office if the cleaning costs $100 it costs $100 for every patient under that insurance. Most insurances will usually still pay a portion of that fee. Sometimes it is the full $100 and you will owe nothing. Sometimes it is just shy of that $100 and you pay a small amount. Most of the time the fee is based off a percentile of usual and customary charges in the zip code and patients end up paying very little. Occasionally, this fee is based off a low fee schedule and the patient will owe a significant amount.

Can I still see you as an out-of-network provider?

The answer is emphatically yes. We want you to still see us and we will still give you the high-quality service that we always deliver at Durango Dental. There is one small caveat…some insurances require that you see an in-network provider or they won’t pay anything and you will be responsible for the full amount. If you are concerned that your insurance plan is one of these, please give us a call and we can do a complimentary benefits check and find that out for you.

Will you still submit my insurance claims?

Yes, we will still submit your insurance claims. We will also do our best to estimate what your insurance will pay on any procedure needed in our office. This is a complimentary service that we offer to all our patients here at Durango Dental.