You went to the dentist, and the receptionist told you the office does not take your insurance. It is a rough moment – you are caught between paying for your care out of your pocket or finding a new dentist. But why does this happen? Are there any ways around it? Here are four common reasons dentists stop taking dental insurance.
- Rosters: One of the common reasons dentists do not work with DHMO/EPO plans is rosters. Rosters are a method insurance carriers use to assign patients to dentists. The dentist is paid monthly based on how many patients are on their roster. Many dentists do not work with DHMO plans that have rosters since they must maintain the monthly roster to be paid, and their payout varies based on the patient count, not on the services they perform daily.
- Claims Payouts: Some dentists do not accept certain carriers' plans because carriers will only cover a certain amount for each procedure, and if a dentist charges more than the covered amount, the patient pays the balance. This is balance billing. Since paying added costs after insurance is inconvenient for patients, dentists only try to accept plans that match their costs.
- Medicaid: If you have Medicaid or Medicare, you may have difficulty finding a dentist accepting your coverage. More dentists opt not to accept Medicaid, with the top reasons being low claims payouts, the paperwork required by Medicaid for a claim, and high turnover and billing issues with Medicaid patients. If you have Medicaid, call and confirm your dentist accepts your coverage before your appointment.
- Accepts NO Insurance: Finally, some dentists choose not to accept insurance. They may prefer to control their costs and decide their pricing for services without worrying about insurance carriers and instead have their patients use in-house or sponsored payment plans to make high-cost procedures accessible. If your dentist does not accept insurance, ask ahead of time about payment plan options that will work for you and your budget.
What do you do if your dentist falls into one of the above categories and does not accept your insurance? Here are three tips to try to make the coverage options available to you work with your dentist.
- Consider a PPO plan for OON Benefits. If you can switch plans, a PPO plan will allow you to see providers outside the dental network. These out-of-network (OON) benefits can save you a lot of money annually if your dentist is OON. But remember that PPO plans come with deductibles and coinsurance you need to be aware of.
- Ask your provider why they don’t accept your insurance: If their reasons are related to rosters, claims, or other common DHMO issues, you might be covered if you switch to an open-access DHMO plan. Open-access networks don’t have rosters and use a basic fee-for-service payment model, making claims easier for dental offices. But check with your dentist to see what carriers they work with before switching!
- Find another dentist. This is a last resort, especially if you have a dentist your family is attached to. But if you cannot switch to a plan your dentist covers, or if your dentist is not accepting any insurance plans, it might be time to find a new provider. Check with your insurance carrier to find a new in-network provider. They should have a customer service line (you can find it on your dental insurance card) or a website/mobile app with a provider search feature!
If you find yourself in a situation where your dentist does not accept your insurance, there are several reasons. While it may seem daunting, there are ways to make the coverage options work with your dentist. Consider switching to a PPO plan for OON benefits, ask your dentist why they don't accept your insurance, or find a new dentist who accepts your coverage. Remember always to research and confirm your dentist's coverage options before your appointment to avoid surprises.
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