One of the most common questions that any healthcare front desk receives is if a certain insurance is ‘accepted’ by that practice. The typical response from most offices will be that “we do accept most insurances”. While the response is accurate, in reality, the question itself is incorrect. In order to understand this, the distinction between in-network and accepting insurance needs to be elaborated.
When a provider ‘accepts’ a certain insurance, all that means is that the
provider can bill that insurance for services rendered. In other words, they can bill as an ‘out-of-network’ provider. With the exception of a few insurance policies that do not pay ‘out-of-network’ providers, the vast majority do pay any provider with the appropriate billing of services rendered.
Typically, when patients calls in with the question of “do you accept my
insurance?”, they are actually hoping that the services are discounted. The
appropriate question would be “are you an in-network provider for my
insurance?” An in-network provider must comply with the contractual
obligations of that policy and as such must abide by the in-network fee schedule, which is usually discounted. In other words, there is typically a limit on how much can be charged by an in-network provider for a certain service. For instance, let’s say the total cost of comprehensive orthodontic treatment of a certain case is $5500. While each practice can come up with their own fee
structure based on their costs, most offices will try to keep their costs around the UCR (usual, customary and reasonable) fees. In this example, as an in-network provider, the provider may have a limit that no more than $4500 be charged for that specific treatment. As such, the patient automatically receives a $1000 discount by choosing an in-network provider. On the other hand, if the provider ‘accepts’ that insurance but is not in-network, they are not obligated to honor the network discount. As such, the net cost of the same service is $4500 with an in network provider versus $5500 with an out-of-network provider. With both providers, the insurance company may pay their maximum allowed amount but the net out-of-pocket expense for the patient is significantly different. The best way to know if your provider is in-network, is to search through your insurance company and sort by your preferences. Alternately, when shopping around, asking if the office is in-network instead of merely accepting insurance. In orthodontics, it is common for patients to reach out to offices based on recommendations by friends and family instead of insurance coverage. This approach is fine but perhaps it is possible to find a provider with great recommendation as well as hopefully in-network which would be a win-win. At P&G Orthodontics, we are an in-network provider for almost all insurance companies.
