Going to the dentist can be stressful enough without having to navigate the fine print of your insurance provider or the complicated rules tied to job-based dental plans. Popular plans include, but aren’t limited to, PPOs (Preferred Provider Organization) and HMOs (Health Maintenance Organizations).
While the rules vary and can get complicated, especially with experienced cosmetic dentists’ costs, PPOs allow you to choose an out-of-network dentist. However, HMOs do not allow you to select out-of-network dentists, so choosing a dentist takes thoughtful consideration. This is especially true for cosmetic dentistry.
In this post, we’ll talk about the many reasons why going out-of-network is a good idea and the consequences if your insurance doesn’t allow it. But first, what exactly is an out-of-network dentist?
What Does “Out-of-Network Dentist” Mean?
An out-of-network dentist isn’t included in your insurance provider’s list of preferred dentists. Many insurers identify health care providers (including dentists) who have agreed to set pricing and coverage terms as “in-network.” These providers are part of a negotiated network that typically offers lower out-of-pocket patient costs. This plan is called an HMO.
When you visit an out-of-network dentist, it simply means that the provider hasn’t entered into a contract with your insurance company. But that doesn’t mean you can’t see them, especially if you have a PPO plan, which usually allows you to choose any licensed dentist and still receive partial reimbursement. You’ll often pay the provider directly and then submit a reimbursement claim based on your plan’s out-of-network rates.
For many patients, the ability to choose a trusted, highly qualified dentist — even if they’re out of network — is well worth the added flexibility and level of care.
Reasons Why an Out-of-Network Dentist May Be the Better Choice
There are many reasons why choosing an out-of-network dentist might be the better option, from greater flexibility to more personalized, long-term care. Here are six compelling reasons it could be the right choice for you.
Freedom to Choose the Dentist:
When you choose an out-of-network dentist, you have the freedom to see any provider you want, not just those pre-selected by your insurance company. That means you’re not limited to a narrow list of in-network dentists. Many patients appreciate this flexibility, whether they already have a trusted family dentist or are searching for a specific specialist.
Higher Quality, Personalized Care:
This is not to say that you can’t find quality dentists in-network. However, dentists who don’t participate in PPOs or HMOs often operate more independently and aren’t reliant on insurance networks to bring in patients. As a result, they tend to focus on long-term relationships, quality over quantity, and customized care. These providers typically spend more time with each patient, tailor treatment plans to individual needs rather than insurance restrictions, and prioritize lasting results. Choosing an out-of-network dentist may be better if you seek more personalized, unhurried, and attentive dental care.
Access to Advanced Treatments and Materials:
Insurance company guidelines regarding treatment protocols, lab work, or materials don’t restrict out-of-network dentists. As a patient, you can access advanced procedures and higher-quality materials that often aren’t available through in-network providers. For example, instead of automatically extracting a tooth, an out-of-network dentist might offer a more advanced, tooth-saving treatment that isn’t typically covered by insurance. Patients also benefit from longer-lasting crowns, more durable restorations, and access to the latest techniques — all of which support better long-term dental health.
Less Insurance Red Tape:
In-network dentists often require complicated and time-consuming approvals and referrals, especially for more advanced procedures like crowns or bridges. Conversely, out-of-network dentists aren’t bound by the same restrictions and don’t need pre-approvals for most treatments. This means fewer hoops to jump through and less time waiting.
Transparent Pricing:
In-network dentists are limited by their pre-negotiated contracts with insurance companies, which are often a maze of complex limitations. In-network billing can be confusing regarding billing, which can lead to unexpected fees. However, out-of-network dentists can be more transparent about their costs since they aren’t trying to work through a contract with an insurer. This freedom allows you and your dentist to be transparent about procedures and fees.
Better Focus on Long-Term Dental Health
Out-of-network dentists have the flexibility to provide the best quality care because, unlike in-network providers, they aren’t hemmed in by insurers’ rules. They aren’t under pressure to deliver quick procedures or ones that easily fall into volume quotas. From early intervention to advanced restorative options, out-of-network providers are often invested in building lasting relationships and helping patients avoid future issues through thoughtful, proactive care.
Will My Insurance Pay for an Out-of-Network Dentist?
The question then becomes, especially for anyone with an HMO, will my insurer pay for an out-of-network dental provider? Below is a basic outline of what insurance programs will pay.
PPOs (Preferred Provider Organization):
If you have a PPO (Preferred Provider Organization) dental plan, your insurance typically pays for a portion of your out-of-network dental care. Then you pay the dentist directly, submit a reimbursement claim to your provider, and receive a reimbursement check depending on your plan’s coverage.
The amount you receive depends on the procedure because different procedures are billed at different rates. For example, your plan might cover 70% of the cost of a crown, leaving you responsible for the remaining 30%. Every plan is different, so reviewing your policy or asking your dental provider to help you understand what to expect is essential.
HMOs (Health Maintenance Organizations):
In contrast, HMO plans generally do not cover out-of-network care. However, some patients still pay for out-of-network providers when they want more personalized care or access to advanced procedures. If you decide to stay within your HMO’s network, it’s essential to research the participating dentists thoroughly and understand precisely what procedures are covered — and which ones are not.
Many HMO plans require patients to request approval before receiving more advanced treatments, such as crowns or bridges. Receiving quality care in-network is possible, but the approval process is often daunting. HMO plans have built-in frustrating limitations. That’s why some patients step outside the network and invest in care, prioritizing outcomes.
Choosing the Dentist that is Right for You
Choosing the right dentist for you isn’t always straightforward, especially depending on your type of insurance policy. Trusted Dentistry is here for you if you’re looking for a dentist in Denver near you. We are an out-of-network dental provider committed to providing the best possible care for our patients.
If you’re looking for general or cosmetic dentistry, we have experienced generalists and specialists who utilize the most up-to-date dental procedures. Request an appointment online or call us directly at (833) 2-Trusted. We’re always happy to hear from current and new patients.