What should you check before an out-of-network visit?
For out-of-network dental billing, first confirm whether the patient's plan has an out-of-network benefit for the proposed care. Then record how the estimate was calculated and who the payer expects to pay. You can't build a useful patient estimate from a coverage percentage alone.
| Question | Record before presenting the estimate |
|---|---|
| Is there an out-of-network benefit? | The answer for this plan and service, with the source and date |
| What fee is the estimate based on? | Your fee, the plan's reimbursement basis if available, and any unknown amount |
| What changes the plan share? | Deductible, remaining maximum, frequency limits, and other applicable terms |
| Who receives payment? | The payer's assignment-of-benefits response and your office's collection process |
| What did the patient hear? | The estimate, its assumptions, and the person who explained it |
The ADA explains that some plans don't provide an out-of-network benefit. Confirm the specific plan before promising reimbursement.
For a simple fictional estimate, use a $1,000 office fee, a confirmed $700 reimbursement basis, and a 50% plan share. With no deductible or other limit in this example, the estimated insurance payment is $350 and the remaining fee is $650. Label both as estimates. When the EOB arrives, compare its actual basis and payment with those inputs before explaining a difference to the patient.
Which number is the plan paying against?
You're probably billing against a number you've never seen. Out-of-network plans pay one of two ways. UCR is built from what offices in your area charge. MAC is the same low fee the plan pays its in-network dentists, and out-of-network offices get handed it anyway. DrBicuspid walks through a case where the dentist's fee was $87 and the plan's MAC was $30.
Most offices bill the full fee, post whatever shows up, and never find out which number they were up against. Here's how to tell, and how to think about what it means for your practice.
Dr. Travis Campbell, who teaches this as The Dental Insurance Guy, puts it simply. Three different fee schedules can apply to one claim. Use the wrong one and every number you gave the patient was wrong. DrBicuspid covers the same ground for out-of-network offices.
You never agreed to a MAC amount, because you have no contract. But it changes what you'll collect from the patient and when, so it's worth knowing before the visit rather than after.
- Does this plan reimburse out of network at UCR or at MAC?
- If UCR, at which percentile?
That second one surprises people. The percentile isn't a standard. Some plans use the 90th. Plenty of carriers set their threshold at the 50th or 60th and pay a percentage of that. The plan picks, and the only way to know is to ask.
Where your fee sits in your own market
The 80th percentile fee is the fee where 80% of dentists in your area charge that or less. It's the level most commonly sold in dental plans, which makes it a useful reference point.
Here's what it tells you. If your office fee is roughly the same as the payer's UCR, your fee is below average for your area, and the carrier is paying a percentage of a threshold it set lower still. Dental Economics has been calling this the UCR shell game for years.
Run a crown through it. Say your fee for D2740 is $1,450, near the 80th percentile in a lot of markets. The plan covers 50% out of network against a $1,200 UCR, so the payer sends $600 and the patient owes $850. In network at a $905 allowed fee, the plan pays $452.50, the patient owes $452.50, and you write off $545.
One more thing that's easy to miss. UCR gets built from fees that offices in your area submit. So a practice that lowers its billed fee to match what insurance pays is lowering next year's UCR for itself and for everyone else in the zip code.
That $545 isn't evenly distributed
The gap is real. Whether you capture it is a different question, and it depends on your market rather than on the math.
Out of network, the patient owes the balance instead of the payer. So the whole thing rests on whether your patients will pay it. Three things decide that:
| Favors out of network | Favors staying on the panel | |
|---|---|---|
| Substitutes nearby | Few. Specialty or scarce skill | Many general dentists on the panel |
| Switching cost | High. Long relationship, referral-driven | Low. The patient found you in the directory |
| Price sensitivity | Low. Affluent or urgent care | High. Cost drives the decision |
One Manhattan oral surgeon we talked to dropped every PPO panel and got roughly 25% more for the same work. He also sits at the favorable end of all three rows, and he said so himself. His read was that in a Rochester or a Detroit, participating is hard to avoid. If you stay on the panel, what's in your PPO contract decides most of that math.
What the panel is actually giving you
The carrier's provider directory is a patient acquisition channel, and it's free. Leaving the panel doesn't raise your marketing budget as a percentage of revenue. It swaps a free channel for a paid one.
So the number worth running isn't a marketing percentage. It's what a new patient costs you to acquire in your market, and how many you'd need to replace. Some practices test that on one plan rather than all of them. Dropping the worst-paying plan with the smallest patient volume is a cheap experiment, and it answers the only question that matters: how your own patients react.
Whether the money actually reaches you
Payers still mail checks to the patient's house. Assignment of benefits is the counter, and 30 states now have laws forcing payers to honor it whether or not you're on the panel. Practices without a signed assignment on file have little recourse when the check goes to the patient.
Then there's the virtual credit card, where the processor takes 2 to 3% of money you already earned. A written request for a check or ACH usually works, though offices tell us the cards keep coming and the request needs repeating. Both practices drew new state laws in the busiest payer reform year on record.
Five numbers worth watching
| What to watch | What good looks like |
|---|---|
| Payment as a percent of your billed fee, by payer | Flat or rising. A drop means the payer switched something |
| Claims paid to your office, not the patient | 100% in an assignment of benefits state |
| Days from submission to payment | Most clean electronic claims pay in 14 to 30 days |
| Payments that arrive as a virtual credit card | Zero |
| Insurance AR over 90 days | 3% or less |
The first row is what tells you a plan moved you from UCR to MAC. Nothing else will. The last row is where the rest of it eventually surfaces, and our post on dental AR benchmarks covers how to read that report.
Seeing where you stand
Last month's out-of-network EOBs answer most of this in one sitting. Three columns: your billed fee, what the payer paid, and how the payment arrived. Divide the second number by the first.
Any payer sitting near a third of your fee is paying you MAC, and you never agreed to it. Anything that dropped since last year is a payer change nobody caught. And when you find an underpayment, it's appealable.
If you'd rather have a second set of eyes on it, Autumn does a free billing consultation. We'll look at what your payers are actually paying against what they owe you, and tell you what we see. It doesn't take anything on your end.
What's the difference between UCR and MAC out of network?
UCR is calculated from fees charged by dentists in your area, at a percentile the plan picks. MAC is a flat maximum the plan pays whether the dentist is in network or out. MAC is normally much lower, and out-of-network offices aren't bound to accept it.
Can a payer send the check to my patient instead of me?
In 30 states an assignment of benefits law requires direct payment to you. Everywhere else, some payers will still pay the patient.
Does out of network mean I can't take insurance?
No. You bill the plan and it pays out-of-network benefits. You're just not bound to a contracted fee schedule, so there's no contractual write-off.
