If you call practically any dentist’s office and ask if they accept a particular insurance you will nearly always receive an affirmative response; the majority of dentist’s offices will gladly bill your dental insurance company for you and apply what they receive against your bill.  The question you should be asking, however, is, “are you in a particular network?”  What might appear to be a subtle difference in terminology can end up costing you hundreds of dollars.

For example, let’s assume you have a dental plan that covers both in and out of network dentists and you need a crown which is covered by your insurance at 50%.  The usual fee, or retail price, for a porcelain fused to high noble metal crown is around $1,200.  If your dentist is in the network it means he has agreed to accept the insurance company’s discounted fee, in this case $672, which means you and the insurance company will each pay 50% of this amount, $336, and the bill will be paid in full.  If your dentist is out of network he will bill your insurance company for the full $1,200 and, depending on how out of network benefits are paid by the insurance company, you will be subject to a balance bill from your dentist for the remainder. 

Your dental insurance will either pay the same amount for an in or out of network or will have a different schedule for an out of network dentist, often based on a percentage of Usual Customary and Reasonable (UCR) charges.  If your insurance pays the same to an in or out of network dentist then the insurance company will pay their $336 and you will be responsible for the balance of $864.  If the insurance company pays at the 80% of UCR level, then they will ‘recognize’ $960 and pay 50% of that, or $480, leaving you responsible for $720.

So, will your crown cost you $336, $720 or $864?  Find out before you have it done by asking the right question.


Ronald Haines, ronald@hcibenefits.com