“We Take Your Insurance” Does Not Mean “We’re In-Network”

It sounds like a simple question: “Do you take my dental insurance?” The dental office responds: “Yes, we take your insurance.”

You schedule your appointment, have your cleaning completed and assume everything is covered. Then, a few weeks later, you receive a bill.

At Nester Insurance, our team fields calls from employees of our employer clients every day. One situation we occasionally encounter is an employee who believed a dentist was in-network because the office said it “takes” or “accepts” their insurance. Unfortunately, those two statements can mean very different things.

“We Take Your Insurance” vs. “We Are In-Network”

A dental office may be willing to accept and submit your insurance without actually participating in your insurance company's network.

When a dental office says it “takes” your insurance, it may simply mean the office is willing to submit a claim to your insurance company so you can receive whatever out-of-network benefits may be available under your plan.

Being in-network means something different. An in-network dentist has a contractual relationship with a dental carrier or network. Under a typical dental PPO arrangement, participating dentists agree to provide specified services according to the terms of their contract, including applicable negotiated or maximum allowable fees.^{[1] (opens in a new tab)}

An out-of-network dentist does not have that same contractual relationship. And that distinction can directly affect your wallet.

How a “100% Covered” Cleaning Could Still Cost You Money

Let's use a simplified hypothetical example. Suppose your dental benefits summary says: Preventive Services — 100%. That may include services such as routine exams and cleanings, subject to the specific terms and limitations of your plan.

It's easy to look at “100%” and think: “Great. My cleaning is free.” But 100% coverage does not necessarily mean the insurance company will pay 100% of whatever amount any dentist chooses to charge.

Simplified cleaning example — not a quote, guarantee, or universal plan rule

The American Dental Association's guidance illustrates this important distinction. For covered services, the in-network calculation is generally limited by the plan's maximum allowable fee, while an out-of-network calculation can include an additional balance toward the dentist's full fee.^{[2] (opens in a new tab)}

That additional amount can become the patient's responsibility depending on the plan, provider and applicable law. This is commonly referred to as balance billing — when a provider bills a patient for the difference between the provider's charge and the amount recognized or allowed by the plan.^{[3] (opens in a new tab)}

Same insurance plan. Same cleaning. Same “100%” preventive benefit. Potentially two very different outcomes.

The Question You Should Be Asking

Those few extra words can make a significant difference. Provider participation can vary by carrier, network and specific plan. Do not rely exclusively on someone at the dental office saying, “Yes, we take that.”

Before Your Next Dental Appointment

1. Check your insurance company's website. Use the carrier's online provider directory and search using the specific dental network associated with your plan.
2. Call the insurance carrier. Use the number on your insurance ID card and ask the carrier to confirm that the dentist is currently participating in your specific network.
3. Ask the dental office specifically about network participation. Do not just ask if they “accept” or “take” the insurance. Ask whether the dentist is an in-network participating provider for your exact plan.
4. Be especially careful before expensive dental work. For crowns, root canals, oral surgery, bridges, dentures or other significant procedures, consider asking the dental office to submit a pre-treatment estimate to the carrier when available.^{[4] (opens in a new tab)}
5. If Nester Insurance manages your employer's benefits, call us. If you are not sure what you are looking at, ask for help before the service is performed.

Why This Matters Even More With Major Dental Work

A surprise $50 or $100 bill after a cleaning is frustrating. A misunderstanding involving a $1,500 or $3,000 dental procedure can be much more painful.

For example, suppose an out-of-network dentist charges $1,500 for a procedure and the dental plan calculates benefits using a lower amount. Your plan may still provide an out-of-network benefit. However, depending on the plan and circumstances, you could potentially be responsible for your normal deductible and coinsurance plus an additional amount associated with the dentist's charge exceeding what the plan recognizes.

This is why knowing whether a dentist is actually in-network matters.

“But I Thought Surprise Billing Was Illegal?”

This is another important misconception. Federal protections under the No Surprises Act protect consumers from certain types of unexpected out-of-network medical bills.

However, the Centers for Medicare & Medicaid Services (CMS) states that these federal balance-billing protections generally do not apply to dental-only insurance plans. They may apply when dental benefits are included as part of a health plan.^{[5] (opens in a new tab)} This is general educational information, not legal advice, and it does not resolve every routine dental-network or balance-billing situation.

That makes understanding your particular dental plan and provider network even more important.

A Call We Would Rather Receive BEFORE the Appointment

Unfortunately, sometimes employees call our office after the dental work has already been completed.

At that point, we can help review the claim, Explanation of Benefits and plan provisions. We can help determine whether something was processed incorrectly and, where appropriate, assist in asking questions or pursuing an appeal.

But there is one thing we cannot do: we cannot go back in time and make an out-of-network dentist an in-network dentist.

The Nester Insurance Takeaway

If you remember only one thing from this article, make it this: “We take your insurance” does NOT necessarily mean “We are in-network with your insurance.”

Before scheduling an appointment or having a significant procedure performed: check the carrier's website, verify the network, ask the right question and, when you are unsure, ask for help.

At Nester Insurance, we believe employee benefits should not end with handing someone an insurance card. Our job is to help employers and their employees understand, navigate and actually use their benefits. If your team has a plan or network question, our service team is glad to help — and you can find more articles like this one in Guides & Insights.

Sometimes a five-minute conversation before an appointment can prevent a much more frustrating conversation after it.

Frequently asked questions

References

1. American Dental Association — Types of Dental Plans (opens in a new tab)
2. American Dental Association — How to Read an Explanation of Benefits Statement (opens in a new tab)
3. HealthCare.gov — Balance Billing (opens in a new tab)
4. ADA News — Dear ADA: Out-of-Network Billing (opens in a new tab)
5. Centers for Medicare & Medicaid Services — Know Your Medical Bill Rights (opens in a new tab)