capline dental services

Is Out Of Network Coverage Worth It?

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February 2, 2021

Out of network coverage can be both beneficial and risky. Billing for out-of-network coverage involves a lot of intricacies and requires the provider as well as patients to be well versed with the process. This article tries to touch upon important aspects of out-of-network coverage.

A few aspects which are important to know about out-of-network coverage are:

  • Financial: As a dental provider, it is crucial to be well-versed with the financial risks associated with out of network coverage for patients.
    • Most of the insurance companies will not provide complete coverage for treatment in out of network care. Most of the HMO and EPO plans do not provide any coverage for out of network services, while other plans such as PPO and POS plans might provide some coverage for the same.
    • Many plans that provide some percentage of coverage for out of network plans also have higher deductibles separately for out of network cares. Therefore the patients who visit an out of network facility pay the deductibles, one for in-network and another for out of network service.
  • Balance Bill: As mentioned before, dental provider, you can charge an apt amount for the treatment for an out of network care. Very few patients are aware of the balance billing procedure and rely on insurance to cover the mentioned percentage of the treatment charge. In various scenarios, a balance bill can cause many hassles for both medical professionals as well as patients. Being aware about the balance billing procedure and educating your patients beforehand on the same is very important. 

It would be easy to understand this with an example. If a dental practitioner charges 20,000$ for treatment for an out of network care and the patient’s insurance policy claims to cover 50% of the same, the patient might assume they will only have to pay $10,000. However, the insurance company might assess the treatment cost and determine the value much lower, say $12,000, and reimburse only $6,000 for the same. The additional cost of $4,000 might come as a surprise for the patient and can create problems in payment settlement.

Educating patients about these intricacies can resolve any future misunderstandings and complications in cash flow.

Important to know scenarios while billing for out-of-network coverage

  • Emergency Care: As per the Affordable Care Act (ACA), insurance companies are instructed to treat any emergency treatment and care for in-network and out-network care equally. Therefore, patients do not require any extra co-payment, co-insurance, and deductible in out-of-network coverage. However, the out of network dental professionals have the authority to charge treatment amounts higher than what is covered by the insurance policy, unless the state has implemented balance billing protection laws. In such cases, it is the responsibility of the patient to settle any extra amount charged by the dental provider.
  • Surprise Balance Billing: There could be many scenarios where a patient visits an out of network dentist in an in-network dental facility, assuming that the dental provider is an in-network provider. Such a situation is referred to as “surprise balance billing”, which can lead to severe complications in payment settlement from the patient side. Therefore, clarification of the policy norms for the scheduled patients is highly advised to avoid any such undesirable circumstances.
  • Out of pocket maximum: There are few insurance companies, which provide out of pocket maximum benefits for out of coverage care as well. However, the maximum amount in such cases is quite higher than usual.
  • Superbills: Out of network care allows dental professionals to circumvent the hassle of filing the insurance claim. A provider simply has to provide a superbill to the patient in regards to the treatment rendered and demand complete payment of the treatment by the patient.

Out of network coverage can be highly beneficial for dental professionals, as it allows them to make important decisions regarding the treatment as well as treatment charges. However, it is highly important to be well-versed with the insurance policy of the patient to avoid any billing complications. To manage the same, a dental provider can also opt for outsourcing the dental billing services from an experienced company that can handle their complete revenue cycle right from patient scheduling till the payment settlement.