In-Network vs Out-of-Network The battle of the network types.

People often want to know if we accept certain insurances. We are In-Network with several insurance companies, but we also work with any plan for which a patient has Out-of-Network Benefits and can choose which provider they want to see, as long as it is not associated with Medicare or Medicaid. This is usually known as a PPO plan (Preferred Provider Option). We also do not accept Discount Plans.
**Please Note: For patient’s using Blue Cross Blue Shield of Alabama plans, we will submit the claim to insurance for your reimbursement but you will need to pay 100% up front for your appointment if you are using one of these plans.

If you have an In-Network only plan and have to pick off of a list, we should be on that list for the following insurance companies/plans:

  • Aetna PPO – not to be confused with an Aetna DMO or HMO, for which you will have a separate list of providers to choose from – we work with Aetna PPO Only
  • Most Blue Cross Blue Shield of GA 300 Level Plans
  • Delta Dental PREMIER plans
    • Because we are contracted with Delta Dental Premier, if you have a PPO plan with them, you are considered to be using your Out-Of Network benefits, but there is a level of Write-Off. You pay the difference between the cost allowed by your plan and our contracted rate with Delta Dental Premier. There are literally hundreds of different Delta Dental Plans like this with different allowances and they will not give us those allowed fees ahead of time, which could result in either a balance or a credit once insurance pays, though you still get the Write-Off benefit of being with Delta Dental.

In Network Versus Out of Network Coverage:

If you come to see us and you are “In-Network,” if there is a difference in the fee for any particular service, between what OUR fee is and what your insurance “ALLOWS” for that service, i.e. “Allowable Fee,” then we Write-Off the difference. For Preventive and Diagnostic services covered at 100%, with no deductible due, this will usually mean that you will not have an out-of-pocket cost.

If you come to see us and you are “Out-of-Network,” it simply means that if there is a difference between OUR fee and the Allowable Fee set by your insurance, you are responsible for the difference. Our fees are based on “Usual and Customary Rates” for our area (based on zip code) and are usually still within or very close to the Allowable Fees set by a lot of insurance companies who base benefits on the Usual and Customary Rates. For most patients using their Out-Of-Network benefits, for Preventive and Diagnostic Services there will often be either a $0 or very minimal out-of-pocket cost. A lot of our patients have out-of-pocket costs between $20 and $40, but still prefer to come to us due our great service, not to mention the Free Laughing Gas,  for which many offices charge $80-$130 per visit!

If your insurance bases coverage off of a FEE SCHDULE, this means that they will pay the designated percentage of coverage for any given service up to the Fee that THEY ALLOW. The fees “Allowed” by plans using a fee schedule are usually much lower than the actual fees at our office or many other offices in the area. You should expect to have an out-of-pocket cost (sometimes a sizable one) if you have an Insurance that pays off of a Fee Schedule.

Also, keep in mind that when you are using your Out-Of-Network benefits, it also means that you are not usually subject to as much downgrading for services. Some insurance companies stipulate downgrades for certain procedures for patients using In-Network Providers. For example, your insurance may estimate to pay a higher percentage if you are going to an in-network provider, but, say, you need a crown on a back tooth. If you are going In-Network, some insurance companies will say they will only pay for the silver, amalgam crown on a back tooth, not the white, porcelain fused to metal crowns that our office does and which almost all patients want. For an in-network provider, you are subject to that downgraded benefit and responsible for the difference. If you go to an Out-of-Network Provider insurance sometimes doesn’t have those same stipulations.

Cigna and Metlife specifically often have very good coverage and allowable fees for Out-Of-Network Services.

Please keep in mind that there are thousands of different insurance plans with all different stipulations for services.

We check on your insurance coverage and submit your benefits on your behalf as a courtesy. You are still responsible for understanding and knowing your benefits.