Out-of-Network dental practice: what it means for patients

An out-of-network dental practice has no participating agreement with a patient’s dental plan. The patient can still visit the practice, but the plan treats the visit differently. This post explains the term using ADA sources, shows what changes for patients and billing, and lists questions to ask an attorney. It is general education, not legal advice.

What does out-of-network mean?

Out-of-network means the dentist has not signed up with the plan’s network. Being out-of-network is the opposite of being in-network. An in-network dentist agrees to the plan’s rules and fees. The ADA notes that “when a dentist signs a participating provider agreement, they agree to abide by the dental plan’s processing policies.” An out-of-network dentist has made no such agreement.

The term applies to a dentist and a plan together. The same practice can be in-network for one carrier and out-of-network for another.

How do PPO and EPO plans treat out-of-network dentists?

It depends on the plan type. The ADA explains that in a preferred provider organization (PPO) “the patient may incur greater out of pocket costs but would still receive a benefit.” In an exclusive provider organization (EPO), which the ADA also calls a “closed panel plan,” the plan pays nothing: “There is no benefit payable to an out-of-network dentist under an EPO plan.”

The ADA adds that EPO plans were typically used by dental HMOs and are “starting to gain popularity with PPOs as a mechanism to control costs.” Plan designs change, so a practice should check each patient’s plan, not assume.

What should the team tell patients?

Clear talk at the start avoids surprises at checkout. The ADA writes that dentists “should be prepared to talk to patients about the repercussions of these types of closed panel plans.” It lists questions to cover: Does the patient understand that no benefit is paid for out-of-network care? Does the patient understand that the patient is responsible to the dentist for the full fee?

A short checklist for the front desk:

1. Verify the patient’s plan and network status before the visit.
2. Explain in plain words how the plan treats this practice.
3. Give the patient a written estimate with the fee and any expected explanation of benefits steps.
4. Send patients with questions about coverage to their plan or employer’s human resources team. The ADA says it is “always a good idea” for patients to do so, “especially before the employer makes a decision to switch the type of dental plan.”

The glossary entry on dental benefits describes how plan types differ.

How do fees work for an out-of-network patient?

A practice that is not bound by a plan’s fee schedule sets its own fee schedule. Rules on how to report fees still apply. The ADA Code of Ethics states: “The fee for a patient without dental benefits shall be considered a dentist’s full fee. This is the fee that should be represented to all benefit carriers regardless of any negotiated fee discount.” It also says it is unethical to increase a fee solely because the patient has dental benefits.

State law, consumer protection rules and some payer rules can add limits on balance billing, fee disclosure and waiving patient shares. Ask an attorney how they apply to your office before you set your policy.

What does a practice weigh before leaving a network?

Leaving a network is a business decision. The ADA publishes a guide on terminating a network agreement for dentists who “are considering terminating the agreement.” The decision affects more than the plan’s fee list. Things to model with a CPA:

• Which patients are covered by the plan, and how many might stay out-of-network.
• How the schedule would change if some of them leave, and how fast new patients could fill the open time.
• What the contract says about notice, treatment in progress and listing in directories.
• How your team would explain the change to patients.

Compare these against the same questions you asked when joining. The dental PPO participation factors post lists the factors, and the PPO participation decision guide shows how to put numbers on them. Do not rely on a rule of thumb for “the right” mix of in-network and out-of-network patients. No published standard sets one.

Why do patients care about network status?

Patients often pick a dentist by plan, so network status affects how they find a practice. The ADA notes that dental plan design “drives coverage and access for employee oral health.” A practice that is out-of-network should be ready to explain value and costs without pressure. Pressure language and promises of savings can also create problems under advertising and ethics rules, so keep all patient-facing wording factual and have an attorney review it.

Some practices pair an out-of-network position with their own in-house plan. The dental membership plans post explains how those work.

Next step

Read the PPO participation decision guide for a framework you can adapt, and bring your contracts and numbers to an attorney and a CPA. To discuss practice finance topics with Dr. Jon Copeland, DDS, a general dentist in Wildwood, Missouri, contact Dr. Copeland about consulting.