Health Tips

In-Network vs. Out-Of-Network

In-Network vs. Out-of-Network, In-Network vs. Out-Of-Network, BioSmile Dentistry Santa Monica, CA

When choosing a dentist, patients who have PPO plans have the option to go to an in-network or out-of-network provider. An HMO plan only allows you to go to a dentist in a specific group. An in-network provider has a contract with your insurance company to accept certain negotiated (i.e. discounted) rates. Currently, the only insurance company that we are contracted with is Aetna and the plan is a part of the Extend Network.

Accepting your insurance and being in-network are not the same thing.

If a patient chooses to see an out-of-network provider, their coverage for services will be based on their individual plan. Out-of-network providers have not agreed to contracted fees with your insurance company. Your coverage will be determined on whether you have a MAC (Maximum Allowable Charge) or UCR (Usual Customary and Reasonable) based plan.

UCR vs MAC

UCR plans provide a fair charge for dental services because it is calculated by how much a certain procedure costs in your geographic area. They set their fees to what 70%-90% of doctors charge in the area. These plans tend to pay more for services and are aligned closer with the dentist’s fees. Your reimbursement from your insurance should be higher.

Under a MAC plan the reimbursement for services is capped at the Maximum Allowable Charge. For example, let’s say you visit a dentist who charges $150 for a cleaning and your insurance says you are covered at 100% but the MAC is set at $100. Insurance will cover $100, and you will be responsible for the remaining $50. With these kinds of plans your reimbursement from your insurance is typically lower.

Should you choose to get dental insurance we recommend asking if you can get a plan based on UCR fees. Your coverage at our office would be much higher than with a MAC plan.

MackUrsula
Insurance TypeMACUCR
ProcedureFillingFilling
Dr. Tooth’s charge$200$200
Acme Insurance Max Amount$150 (PPO Fee)$180 (90th percentile UCR)
Service level covergage %8080
Insurance pays$120 (80% * $150)$144 (80% * $180)
Members Pay$80$56

Benefits of an Out-of-Network vs In-Network Dentist

  • Higher Quality of Dental Work: For cosmetic or complex dental services, it is better to choose a dentist that will suit your needs and who has expertise in the field. This may mean you need to see an out-of-network provider.
  • Save Money: You avoid running the risk of getting low-quality dental treatment just because you must choose a dentist from your in-network list. Unfortunately, in the dental field cheaper does not equal better.
  • Insurance Reimbursement: Out-of-network does not mean you cannot use your insurance. If it is a PPO plan you can still use your insurance to get some of your expenses reimbursed.
  • More Freedom: By choosing out-of-network, you will be free to pick the dentist who performs treatments in the way you want, especially if you are looking for a dentist who cares for your overall health. Most offices with a biological/holistic approach are out-of-network providers.

Reasons Why Our Office is Out-Of-Network

  1. We are able to provide our patients with the highest standard of care while not being limited by contracted insurance fees. This allows us to choose excellent local labs, to not compromise on the quality of our long-lasting non-toxic materials and to deliver the highest quality of dentistry.
  2. This enables us to prevent you from having further dental expenses by avoiding revisiting the same procedures in the future.
  3. Most dental insurance companies base their fees on traditional dentistry. In the past, most dentists used amalgam fillings to fix cavities, disregarding the impact on mercury on your body health. We perform less invasive procedures, reduced toxicity treatments and offer relaxing techniques.

We hope this helps to provide a clearer understanding of insurance and what we accept in our office. If you have any questions, please feel free to reach out to us. We love our patients and are incredibly grateful that you choose us for your dental needs.

– Dr. Lorene Boisvert and Our Team

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