“In Network” versus “Out of Network”
If you read my last blog entry about dental insurance, you should be well versed in how dental insurance and medical insurance differ. Beyond what’s been previously discussed, there are also differences in the issue of “in” versus “out” of network. We all know when it comes to medical insurance, it’s better to see an in network Doctor. Not only does this mean the insurance plan will pay for a greater percent of the cost of your visit, but it also means that the fee for the procedure you’re having is drastically less. We’ve all seen the EOBs (Estimation of Benefits) that arrive in the mail showing the amount “not allowed” by the insurance company. This cuts fees down, sometimes in half, of the non-insured, “cash” fee. It’s pretty obvious that to save money on medical healthcare you need to see an in-network provider.
This issue gets a little gray when it comes to dentistry. And, at this point I’m speaking only of PPO insurance plans. When I have a new patient coming in, I often get a print out from their insurance company showing their dental insurance benefits based on categories. The categories will be things like Preventive (x-rays, exams, cleanings), Restorative (fillings), Periodontics (deep cleanings and gum care), etc. The print out will usually show the in network provider fees and the out of network provider fees—meaning what the insurance company will pay for treatment in all of these categories. Half of the time the fees are the same. That means you can see any dentist, in network or not, and receive the exact same benefit from your dental insurance. Which, to review my last entry, usually isn’t too much.
I see this most often from State of California and Sacramento County plans. They work with Delta Dental of California, which offers fairy flexible benefits to their subscribers. Delta offers different PPO plans, the DPO and Premier. I’m a provider for the Premier plan only, but that doesn’t mean people with the DPO plan can’t see me, they may just pay slightly more out of pocket, depending on their plan.
All that being said, there are some screwy insurance plans out there and you have to know your individual one in order to reap the most benefit from it. There are some plans out there that don’t have very many providers listed with them. This can seem frustrating as the consumer, but believe me, it’s also frustrating for the dentist. Take, for instance, the fees for doing a filling. Depending on the size of the cavity involved, the filling may be on one, two or three “surfaces” of the tooth. My cash fee for a one surface filling is $191. If I see a patient with Delta Premier, my fee on file with them is $185. That means between the insurance companies reimbursement and the patient’s co-pay, I will be paid $185 for a filling that truly costs $191. Not a huge difference, but it could be. If I saw a patient with a plan from Premier Access, the insurance company will pay whatever it decides to pay, and the patient has to make up the difference because I’m out of network. But, if I were “in-network” for the insurance company, I would have to do the same filling on the same tooth, but only be allowed to receive $95 (for example). To do the $95 filling costs me the same as the $191 filling in terms of my supplies, staff salary and time, but yet I can’t get paid what it really costs, which is $191.
I can tell you that this gets old really fast. As a dentist with my own practice, my overhead is steep, and if you do the math, I would have to do twice as many fillings to make the same amount of money if I were a provider for this insurance. So, it doesn’t pencil out. It doesn’t make sense. That’s why it’s important for the public to understand this. I’m not a huge corporation like Sutter or Mercy, who can negotiate all kinds of discounts because of buying power. I’m just me, and I have to look out for myself and my own financial interests. I treat my patients well and take the time to care for them properly. If I had to see twice as many patients this would be impossible.
Next post will be about Discount plans like Smile Savers.
Yours in good (dental) health,
Dr. Stefanie Shore, DDS