Is it worth paying more to keep your out-of-network dental provider?

Paying more to keep an out-of-network dental provider may be worth it if you’re in the middle of treatment, have complex dental needs or value an established care relationship. If your needs are routine and switching could save you significantly, an in-network provider may make more sense. 

What you will learn in this article: 

• Staying with an out-of-network dental provider may be worth the extra cost if you are in the middle of treatment or rely on an established care relationship. 

• Switching to an in-network provider may make more sense if the cost difference is large and your dental needs are routine.

• Before deciding, compare your actual out-of-pocket costs for both options instead of assuming one will be cheaper.

• Your treatment needs, comfort level and how long you expect to stay on the plan should all factor into the decision. 

If your current dental provider is out of network and you’re weighing whether to stay or switch, schedule an appointment with an Aspen Dental provider. They can review your oral health and treatment needs so you have a clearer picture of what a change in care could mean. 

How out-of-network costs work 

In-network dental providers agree to set fees with your insurer. Out-of-network dental providers don't. So your plan pays less, and you pay the gap. 

Here's how the math usually works. Your plan sets what it calls an "allowed amount." It pays a share of that amount. Your dental provider may charge more than that amount. You pay the difference on top of your regular copay. 

That gap is called balance billing. It can add up fast, depending on the treatment. 

Your deductible and annual maximum also shift. Out-of-network care often has a higher deductible. Your plan's yearly cap on benefits may be lower for out-of-network providers too. 

How to estimate your real price difference 

Before you decide, get the actual numbers. Here's how. 

Call your insurer. Ask what your plan pays for out-of-network care vs. in-network care. Ask about the deductible difference too. 

Call your dental provider's office. Ask for the fee for any treatment you expect in the next year. Ask if they'll submit a claim on your behalf. 

Then do the math. Compare what you'd pay out of pocket at each option for a full year of your expected care. 

For routine care, the gap may be small. For bigger work, it can be much larger. 

When staying with your dental provider makes sense 

Cost isn’t the only thing on the table. Some situations may make continuity of care worth the extra expense. 

You have ongoing or complex treatment

If your dental provider is already treating you for gum disease, a root canal or a multi-step restoration, changing offices may make the process harder. A new dental provider will need to review your records and understand what has already been done. 

You have special needs

If you have dental anxiety, a disability or a condition that makes care harder, a dental provider who knows you can be a real asset. Trust takes time to build. 

You’ve had ongoing decay issues

The National Institute of Dental and Craniofacial Research (NIDCR) explains that continued decay can weaken enamel until a cavity forms. Once that happens, the tooth needs a filling.¹ If your dental provider is monitoring a problem area, ask how that history and your records would transfer to a new office. 

Your child has sealants or preventive care

NIDCR explains that sealants cover the pits and grooves in children’s back teeth, helping keep food and germs out of places that are hard to brush.¹ If your child’s dental provider checks those sealants over time, make sure that information is included in any records sent to a new office. 

When switching to an in-network dental provider makes sense 

Switching may make more sense when the cost gap is large and your dental needs are straightforward. 

If you are healthy and mainly need cleanings and checkups, switching may be easier because your needs are routine. This does not mean every dental provider or office is the same, so compare your options before choosing a new one. 

If you have not built a deep relationship with your current dentist, changing offices may also cost you less in continuity. 

A simple framework to help you decide 

Ask yourself these four questions: 

1. What is my actual cost difference for this year? Run the numbers before you assume it's too high or fine to ignore. 

2. Am I in the middle of any treatment? If yes, consider finishing it first before switching. 

3. Do I have needs that depend on trust and history? Anxiety, complex dental history or special needs tip the scale toward staying. 

4. How long do I plan to stay on this plan? A one-year plan may not be worth disrupting care. A long-term plan changes the math.

Once you’ve compared the costs and considered your treatment needs, choose the option that makes sense for both your care and budget. If switching looks like the better fit, ask your dental provider to review your records and help you continue your care. 

Is it worth paying more to keep your out-of-network dental provider? FAQs 

Still deciding whether staying with an out-of-network provider is worth the extra cost? These answers cover a few common questions. 

Can I switch mid-year if I change my mind? 

Dental plans mostly lock you in at open enrollment. Outside of a qualifying life event, you may not be able to change until the next enrollment window.²

Will my new dental provider have access to my old records? 

You have the right to request a copy of your records.³ Ask your current dental provider for X-rays and notes. Bring them to your first visit at a new office. 

What if my out-of-network dental provider refuses to file my insurance? 

Some don't file on your behalf. You'd pay in full upfront, then submit the claim yourself. Ask your insurer for the out-of-network claim form. 

Does my out-of-network dental provider have to tell me what I'll owe before treatment? 

Not automatically, but you can ask. Many dental offices can request a "predetermination of benefits" (also called a pretreatment estimate) from your insurer before work begins, showing roughly what your plan will cover based on your remaining eligibility and plan maximum. It's voluntary, not required in most cases, and it's not a guarantee of final cost. Your actual coverage is confirmed at the time treatment is provided.⁴

Sources 

¹ National Institute of Dental and Craniofacial Research: “The Tooth Decay Process: How to Reverse It and Avoid a Cavity.” https://www.nidcr.nih.gov/health-info/tooth-decay/more-info/tooth-decay-process
² HealthCare.gov: "Getting health coverage outside Open Enrollment." https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/ 

³ American Dental Association: "Ownership of Dental Records and Radiographs." https://www.ada.org/resources/practice/practice-management/ownership-of-dental-records-and-radiographs
⁴ American Dental Association: "Pre-Authorizations." https://www.ada.org/resources/practice/dental-insurance/pre-authorizations