Navigating Out-of-Network Dental Benefits: Making Informed Decisions

Choosing the right oral surgeon can be daunting, especially if the surgeon you trust is not in your insurance network.

Yet, if your dental plan includes out-of-network (OON) benefits, you may still receive coverage for wisdom teeth removal, tooth extractions, sedation, or dental implants. In this guide, we’ll help you understand OON benefits, from financial considerations to how to maximize your coverage.

By the end, you’ll feel empowered to make informed decisions about oral surgery in Nashville—even if your dentist is out-of-network. 

Understanding In-Network vs. Out-of-Network Care 

Basic Definitions 

• In-Network Provider: A dental professional who has a contract with your insurance. They agree to set (discounted) fees. In return, the insurance pays a larger share of these expenses. 
• Out-of-Network Provider: A dentist or oral surgeon who is not under contract with your insurer. Their fees may be higher, but if your policy covers OON care, the insurance still contributes a portion. 

Key Differences in Coverage 

• Fee Negotiation: In-network providers adhere to preset, negotiated rates, often leading to lower out-of-pocket costs. 
• Coverage Rates: Out-of-network coverage usually involves a higher deductible and lower percentage of coverage. 
• Provider Options: Using out-of-network benefits dental plans expands your choice of specialists. This can be particularly advantageous for complex procedures, such as specialized wisdom teeth removal or dental implant placement. 

 Benefits of Choosing Out-of-Network Providers 

1. Access to Specialized Care: Complex procedures sometimes call for a specialist. An out-of-network surgeon may have advanced training in sedation or expertise in complicated extractions. 
2. Freedom of Choice: You’re not restricted to providers in your plan’s directory. If we are not in network with your insurance, and you have out-of-network benefits, you can still receive some reimbursement for care at our practice.  
3. Potential for Higher Quality Care: While in-network does not necessarily mean lower quality, an out-of-network practice might offer more personalized services or advanced techniques that align better with your needs. 

Financial Considerations 

Understanding UCR (Usual, Customary, and Reasonable) Fees 

Insurance companies pay out-of-network benefits based on UCR fees—what they consider typical for a given service in your region. 

• Fee Matches UCR: If your surgeon’s charge is at or near the UCR rate, your share of the cost will be smaller. 
• Fee Exceeds UCR: You might owe the difference between the full charge and what your insurance deems “reasonable.” 

Out-of-Pocket Costs 

• Higher Deductibles: You must often meet a larger deductible before insurance coverage starts. 
• Coinsurance: After hitting your deductible, your plan might cover a percentage of the UCR cost (e.g., 50%), leaving you responsible for the rest. 
• Balance Billing: If your surgeon charges above the UCR, that additional amount is your responsibility. 

Reimbursement Process 

1. Pay the provider (often in full) at the time of service. 
2. Submit a claim (yourself or with help from the provider’s office). 
3. Receive a reimbursement check or direct deposit from your insurer for their portion of the allowed fee. 

 Steps for Using Out-of-Network Benefits 

If you decide to use out-of-network benefits for wisdom teeth or other oral surgery procedures, these steps can help you do so effectively: 

1. Verify Your Coverage: 
   • Review your policy or contact your insurance company to confirm out-of-network coverage. Our office can assist you with this.  
   • Ask about deductibles, coinsurance rates, and whether any waiting periods apply.
2. Obtain a Cost Estimate: 
   • Ask the oral surgeon’s office for an itemized treatment plan.
   • The estimate should include procedure codes, fees, and any additional costs (e.g., sedation, X-rays).
3. Pre-Treatment Authorization (if needed): 
   • Some plans require pre-authorization, especially for major services like dental implants. 
   • Your oral surgeon can help with the necessary paperwork to ensure the service is deemed medically necessary.
4. Discuss Payment Options:
   • Since you’ll likely pay out-of-pocket first, ask about financing or payment plans. 
   • Check if the office accepts credit cards, third-party financing, or offers in-house payment options. 
5. File Your Claim: 
   • Obtain an itemized receipt or “superbill” from the provider after treatment. 
   • Complete your insurance’s claim form (often available online), ensuring all details match what’s on file with your insurer (name, address, ID number). 
   • Attach the receipt and any supporting documents (e.g., X-rays, proof of payment) if required. 
6. Follow Up with Your Insurer: 
   • Monitor your claim status. 
   • If you don’t hear back within the expected timeframe, call to confirm they have all documentation. 
   • Review your Explanation of Benefits (EOB) to see precisely what was covered, and what remains your responsibility. 
7. Receive Reimbursement: 
   • If everything is in order, the insurer sends you a check or a direct deposit for their share. 
   • If you notice discrepancies or if coverage is less than expected, contact your insurer for clarification. 

Example: How Jane Used Out-of-Network Benefits for Wisdom Teeth Removal 

Jane, a college student in Hermitage, was advised by her dentist to have her impacted wisdom teeth removed. The recommended oral surgeon was out-of-network on her PPO plan, but Jane proceeded because: 

• The surgeon had specialized training in difficult extractions and IV sedation. 
• Jane’s insurance covered out-of-network benefits at 50% after a $200 deductible. 

Cost Estimate:
The total for all four wisdom teeth plus IV sedation came to $2,400. Jane paid the office in full on surgery day. 

Filing the Claim:
Using the itemized receipt, Jane completed her insurance claim form. The surgeon’s staff provided procedural codes and diagnostic details. 

Insurance Reimbursement: 

• Insurance’s allowable amount (UCR) for this surgery was $2,000. 
• After Jane’s $200 deductible, the plan’s 50% coverage was applied to the remaining $1,800, resulting in a $900 reimbursement. 
• Jane’s final out-of-pocket cost ended up being $1,500 ($2,400 minus $900). 

 Despite the higher cost compared to an in-network provider, Jane prioritized specialized care and still received some financial relief from her insurance. 

 Tips for Maximizing Out-of-Network Benefits 

1. Pre-Treatment Estimates: Request a predetermination of benefits from your insurer to see what they’ll likely cover. 
2. Documentation Requirements: Keep all receipts, X-rays, and treatment plans organized. Documentation helps you file accurate claims. 
3. Stay Proactive: Check in with your insurance to resolve any issues. Misfiled or incomplete claims can delay your reimbursement. 

Questions to Ask Your Insurance Provider 

• Do I have OON benefits?: Confirm coverage and any policy restrictions, like annual maximums or waiting periods. 
• What is my OON deductible and coinsurance rate?: These figures determine your out-of-pocket expenses. 
• Is pre-authorization required for certain surgeries?: Knowing this helps avoid claim denials. 
• How is reimbursement handled?: Ask for a timeline and instructions on filing claims. 
• Are there any additional fees or plan limitations?: For instance, you may have a maximum yearly coverage limit. 

Working with Our Office 

Hermitage Oral Surgery aims to simplify out-of-network care: 

1. Insurance Verification: We’ll check your coverage details to provide an estimated cost and potential coverage for your procedure. 
2. Payment Options: We accept credit cards, financing, and other arrangements to make your procedure more manageable financially. 
3. Support with Paperwork: Though you’ll pay us directly, we’re here to help with claim forms and coding. We want you to get the most from your dental benefits, even if they’re out-of-network. 

FAQs 

Q: What is the difference in cost between in-network and out-of-network?
A: In-network providers typically offer reduced fees per contracts with insurers. Out-of-network surgeons can charge full price. While your insurance may still contribute, you’re likely to pay more out-of-pocket due to higher deductibles, lower coverage percentages, and the potential for balance billing. 

Q: When can you use out-of-network benefits?
A: You can use OON benefits if your plan includes them. Many PPOs offer some out-of-network coverage, whereas HMOs seldom do outside emergencies. Always confirm with your insurer beforehand. 

Q: How do I get reimbursed for out-of-network services?
A: Generally, you pay the out-of-network provider in full on the day of treatment. Then you submit a claim form and an itemized receipt to your insurance. After processing, you receive a reimbursement check or direct deposit for the covered portion. 

Final Thoughts 

Having out-of-network benefits dental coverage can open the door to specialized oral surgery care, from wisdom teeth removal to dental implants, without restricting you to in-network providers only.

By following the steps detailed above—verifying coverage, getting cost estimates, and filing claims properly—you can make an informed decision that balances quality of care with your budget.

Whether you need complex extractions or advanced implant procedures, oral surgery at Hermitage Oral Surgery can still be accessible and partially covered, even if we are out-of-network.