Can your dentist charge more than allowed by the contracted amount shown on the Explanation of Benefits (EOB) statement issued by your insurance company?

Providers that are in-network with PPO or EPO plans agree to accept the allowed amount as payment in full. However, they can still balance bill you for uncovered services, copayments, deductible, and more.

On the other hand, out-of-network providers can charge whatever they want because the insurance contract does not bound them. Learn the right questions to ask before booking an appointment and avoid paying extra.

Also, be aware that some plans types do not constrain dental pricing.

Network Dentists Charging More than Insurance Approves

Dentists who are in-network with a PPO or EPO plan cannot charge more than allowed by the contracted amount when the insurance company approves the claim. This contractual figure is the limit they can bill patients for covered services.

However, expect to fund beyond the copayment for approved treatments, and perhaps pay higher prices when your insurance denies claims for one of three possible reasons.

Excluded Services

In-network dentists could charge extra when your insurance does not cover a particular treatment. Your plan will not approve every recommended or requested procedure. Therefore, the contracted amount might apply to every situation.

Claim denials can fall into three categories.

  1. Excluded services are not part of the coverage and can include cosmetic procedures (tooth whitening, veneers, and implants), orthodontia, and other ancillary treatments
  2. Standards of care denials happen when the issuing company determines that a less costly procedure can treat the problem effectively such as amalgam versus resin fillings for molars
  3. Frequency ceilings limit the number of treatments in a period, such as one quadrant every two years for root planing and scaling (deep cleaning)

Patients can find the allowed amount in a previous EOB when denied for the third reason (frequency ceilings). Use this figure to dispute higher fees if the dental office bills the entire amount at retail prices.

Above Copay

PPO in-network dentists can balance bill patients above the copayment for approved services. It is standard industry practice for offices to seek reimbursement for the portions of the contracted amount that insurance does not pay.

Every dental plan has cost-sharing features, which are the patient’s responsibility.

  • A copayment is a fixed dollar amount due for each date of service
  • Co-insurance is a percentage of the allowed amount owed by the patients
  • A deductible is a member-paid amount for covered services before insurance kicks in each year (individual and family)
  • Annual benefit maximum is the total claim payments the plan will make during the plan year (individual and family)

Therefore, prepare to receive a balance billing statement from your in-network dental office after the issuing company processes each claim. The patient has the financial duty to fund the difference between the allowed amount and what the plan pays.

Non-Network Dentists Charge Market Rates

Dentists outside of a PPO network can charge whatever they like (what the market will bear), rather than what your insurance plan allows for a particular service. There is no contracted amount because the provider did not reach a binding legal agreement with your insurance company to accept that figure as payment in full.

Also, your dental might plan might not be a PPO and could have a design that does not feature contract rates. Then, your dentist might “accept” your insurance, but that does not equal being in-network.

Plan Design

Dentists often charge whatever they like, and the local market will support because the insurance plan permits this billing practice. Dental plans do not all work the same way.

Instead, the industry markets a wide array of designs that do not always include a contracted amount.[1]

  • Table of Allowance (Supplemental) designs pay a set amount per procedure independent of what the dentist charges
  • Indemnity (traditional) plans reimburse a percentage of charges based on the Usual Customary and Reasonable (UCR) fees for a local area
  • Preferred Provider Organizations (PPO) are indemnity plans mixed with a network of dentists under contract to deliver services for pre-defined fees (the allowed amount)
  • Health Maintenance Organizations (DHMO) prepay dentists to treat member patients at no further cost or a minimal fee
  • Direct reimbursement pays a straight percentage of whatever the dentist decides to charge for covered services
  • Exclusive Provider Organizations (EPO) are closed panel groups that honor claims from a limited pool of local dentists

Identifying Dentists

One critical skill all patients should learn when shopping around for the best local dentist is learning how to verify network status with your PPO insurance plan. Take measured steps to arrive at a reliable answer, understanding that it is your responsibility to understand your coverage.

  1. Use the provider directory published by the issuing company to find local dentists that participate in-network with your PPO plan while being fully aware that the web listings might be out of date
  2. Ask the practice manager or person responsible for billing to verify their contract status being careful to use precise wording
    1. Accept insurance means they will happily cash claims checks as partial payments towards any amount billed for treatment
    2. Participate means they signed a contract with the PPO plan and agreed not to charge above the allowed amount for covered services

Finally, submit a small claim for preventive care (exam and cleaning) and view the resulting EOB after processing. Look at the “Network Savings” and “Patient Responsibility” columns to verify network status.

Footnoted Sources:

[1] American Dental Association – Plan Types