By Elizabeth DiBona, Guest Writer

So, your dentist is no longer contracted with your dental insurance (ie, going “out-of-network”). Here's why that might be a great thing for your teeth.

“Out of network,” “unrestricted provider,” “not contracted with dental insurance corporations,” and “fee-for-service:” Essentially, these all have similar meanings, and your dentist might have a specific way to describe what being out of network is. Dental insurance may describe it in a confusing way, like, “You need to find a new dentist.” But you do not. In fact, you probably should not, because, as I will summarize below, using a dentist who works independently from dental insurance might be great for your dental health.

To summarize the main types of dental practices out there right now:

  1. Privately owned and completely independent from dental insurance (aka fee-for-service, out of network, or unrestricted provider). This is my practice now, although previously, for four decades, we were in-network with one insurance company.
  2. Privately owned dental practices that still contract with insurance companies. These offices are often given extremely low, below-standard, and customary procedure reimbursement fees from the insurance companies they contract with (hence the shift I am writing about).
  3. Private equity-owned dental practices.

A lot of shakeups have occurred since the pandemic, and one thing you might be noticing is a shift with privately owned dental practices. Many dentists are throwing off the shackles of dental insurance and practicing independently. Decision-making and quality control are shifting back into the hands of dentists. Why now? Staffing shortages, increased overhead, and the inability to control our reimbursement fees have led to this shift.

Another result of the pandemic is that low interest rates made scooping up dental practices more enticing for private equity groups; thus your dental practice might be purchased by a large corporation. This is almost the other end of the spectrum from an office that ended its contract with insurance corporations. Which one is better?

 

Why I Am Strictly a Fee-for-Service Dentist

Full disclosure: I have a private practice that is not contracted with any dental insurance companies (we are fee-for-service). I took over the practice from my father, and I was fortunate enough to be in the position of having a loyal following of patients who understood why we could no longer provide quality dental care while contracting with dental insurance plans. However, I have plenty of colleagues who are looking to retire, and private equity groups are paying above-appraised value to purchase the practice—thus, many of my fellow dentists have gone the other route. New dental school graduates have been dismayed how they could not compete on bids for purchasing existing private practices because the bank would not lend them above-appraisal value. That's one way private equity has an advantage over new dentists. Another path some dentists take is completely starting a practice from scratch. Although this is a less common path and it's certainly filled with its own set of challenges, there are some fantastic dentists out there using this model with incredible success.

Other private practicing dentists find themselves in limbo, trying to figure out what direction to take: drop insurance altogether, tough it out with the insurance companies and increase procedure volume to make up for the low reimbursement fees, or sell to PE? These dentists have high-quality practices but are still contracting with the big insurance giant. However, their ability to practice without interference from dental insurance is dwindling (for example, denied claims for administrative reasons, denied claims because some plans don’t cover basics like periodontal therapy for moderate to severe gum disease), and these dentists are very eager to drop insurance plans and practice independently. But they are concerned about losing patients.

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Simply put, dental insurance is not catastrophic coverage, like medical insurance. Patients do not necessarily need it. Some might argue it actually causes more harm than good. Why? Because dentistry involves materials, technology, and highly skilled hands.

More information here:

Is Dentistry Worth It? Comparing It to Being a Pediatrician, a Planner, and a Plumber

 

Downsides of Low Insurance Reimbursement

If you start reimbursing much less than is needed for high-quality dental care, you start getting the following potential downsides of low reimbursements:

 

Dental Assistants Placing Fillings

Let me just make a note that placing a composite filling in your mouth is still one of the most technique-sensitive things I do today. I routinely place dental implants, perform sinus bone augmentations, do cosmetic work, and so on, but placing white composite fillings involves a lot of possibility for error—like getting air bubbles, voids, and inaccurate margins, even for those of us who are incredibly experienced. Post-op sensitivity may increase with someone who is not as highly trained at doing fillings. However, dentists are training their assistants to do the “placement” part of the filling for better efficiency, so they can move on to the next patient. This is not giving the patient the best quality care.

 

Dental Hygienists Given Shorter Appointment Times

Remember the dental hygiene shortage after the pandemic? Well, guess what? They want more money to return to work. And they DESERVE it because removing plaque from your teeth is backbreaking work, and if you don’t give them enough time or money, there is likely going to be plaque left behind. Plus, the less time you spend with your hygienist, the less time they can educate you, diagnose something before the dentist comes in (or alerts the dentist to something if you are not due for an exam), or review a customized home care plan with you. Again, the patient will suffer.

 

Cheaper Dental Materials Will Be Used

Do you know that it’s clinically acceptable for dentists to order dental crowns from anywhere in the world? Do you know that labs are hiring inexperienced dental technicians to meet the demand for “cheaper” dental crowns? The filling materials we order can range tremendously in price as well, with the higher-end ones costing about 5X that of the lower-end ones. Let me put it this way: everything I put in my own mouth (I’ve had fillings, crowns, etc.) is the EXACT material made by the same exact lab technicians that make your crown in my office. I’ve even heard of some dentists using different materials/labs for different insurance plans (although this doesn’t sound ethical or legal to me . . . but I think the dentists are just trying to make it work for the patients). In other words, if your dental plan reimburses peanuts, you just might be getting peanuts for materials in your mouth!

 

Dentists Seeing Higher Volume of Patients

out of network dentists

Dentists are “proceduralists.” We are looking through loupes all day long and holding extremely sharp objects over your face. Meanwhile, patients are terrified of us. This can wear down our capacity to treat everyone at 100% of our ability. After switching to our new service model, my schedule slowed down, and I realized that if my brain isn’t completely fried, I can think more critically about my treatment plans. I have time to collaborate with my peers on complex cases. I can be a better dentist.

Now, it might just sound like “out of network” dentists are catering to the rich, but that is not the case. I have an office filled with people who want the best quality in their mouth, and (similar to building a house with high-quality materials) they want it to last a long time. My patients are house cleaners, police officers, teachers, veterans, retirees. Of course, we have many well-off individuals as well. Most of the patients who left my practice after we went “out of network” were those who still take their Disney vacations, still have their ski homes, and still drive their luxury automobiles. But they preferred to save money by going to the “in-network” dental practice.

More information here:

A Dental Career Reimagined — I Thought I’d Be Rich But I Found Wealth in Another Way

How Much Does It Cost to Become a Dentist?

 

Benefits of Fee-for-Service or Out-of-Network Dental Practices

What benefits might you see popping up at fee-for-service or out-of-network dental practices, like my practice?

 

In-House Membership Plans

Dental membership plans are about $50-$60 per month in most practices. This is a membership through your individual dentist, not an outside company. It appeals to patients because they can take more control over their health while knowing their dentist can see them for same-day emergencies. These dentists use long-lasting crown materials, and we have time to attend continuing education training and to keep up with the latest technologies. Plus, out-of-pocket expenses are often similar to those going online and purchasing name-brand dental plans. But with in-house dental membership plans, you don’t have a deductible, you don’t have rejected claims, and you don't have maximum benefits. Instead, you have a dental team that is attentive and caring.

 

Treatment Plans Based on Your Actual Needs

These are the dentists who are making treatment plans based on your oral health needs and not just “what insurance covers.” Patients do not benefit when insurance has a seat at the table in deciding what care benefits them. For example, I have no problem telling a patient the tooth needs a crown and not just a filling. But if insurance covers “just a filling,” some dentists might not feel as confident telling patients what their mouth would benefit from, because they are concerned patients will get upset with out-of-pocket expenses. I tell my patients, “This is what I would put in my sister’s mouth.”

Somehow, patients have become used to insurance dictating what is needed to keep them healthy. But dental insurance functions more like a middleman, causing costs to increase without really benefiting you in the long run.

 

Well-Trained Teams to File Your Insurance Claims for You

You might also see practices catering more to you. We have a dedicated insurance claim employee who, as a courtesy, takes your claim form and files it for you.

 

Dentists Who Can Take on More Charity Work

Having more free time during my clinic day allows me to take on cases from our New Hampshire dental society for free care, which has been incredibly rewarding.

 

Private Equity-Owned Dental Practices

What might you see in private equity-owned dental practices?

First off, you won’t know it’s owned by private equity, because they look exactly the same as before they were purchased. They don’t call themselves “Private Equity Dental,” but if you ask their staff, “Who owns the practice?” you can figure it out that way. One of the biggest private equity groups in the country started its own dental school. I can’t yet comprehend the full implications, but it means that private equity is starting to train a lot of dentists.

You will also see lower fees at PE-owned dental practices. Most of these offices take a lot of insurance plans, and because they own hundreds of offices, they have more negotiating power for insurance reimbursement rates and materials/lab work.

In general, these practices might hire students right out of school, burdened with dental school debt, but the private equity companies offer a lot of CE training as a trade-off. Typically dentists who work in these corporate settings give up some autonomy, but the tradeoff is that someone else runs the practice for them, does the staffing, and deals with the headaches of the business side of things.

The downside of not having the autonomy to choose your dental labs, choose your dental materials, or choose the amount of time you have per procedure is that quality can suffer. Dentists are picky people. For example, I use three different dental labs, one for All-on-X implants, one for crowns, and one for dentures. If I were limited to just one lab, I couldn’t search for the best technician possible for the case. Filling material is another area I’m extremely picky about; there are a million and one options out there for composite filling restorations. I choose the ones that have the most durability and cause the least amount of post-op sensitivity.

 

Potential Impact on Patient Care

My overall feeling toward PE-owned practices is that they will focus on volume and speed over quality. Many PE practices have quotas for the day, and some give out bonuses based on the volume of dentistry performed each month. High volume does not typically go hand in hand with high quality, and I believe quality of care suffers. I know some amazing dentists who work for private equity, so there probably are some great dentists out there who will be upset at my generalization. But I truly believe quality improves with a smaller, more controlled setting. Furthermore, private practices like mine have a dentist (me) who will be here in another 10, 15, or 20 years, so I want your dentistry to last as long as possible. I specify that labs use the best Certified Dental Technician to do the case. In PE practices, many of the dentists move from location to location. Or they do it until their debt is paid off, and then they try to go into private practice. So, if you have a problem with a dental crown that was placed a few years back, you might be out of luck.

Since this is a financially focused group, I would be remiss if I failed to mention that, in the long run, you will likely also win out in the end with money spent on dental work. Again, think better materials, better labs, and better-trained dentists and hygienists as the result of an office going “out of network.” Your dentistry will likely last longer, your dentist/hygienist/assistant will love what they are doing more, and they will likely give you dental work that will last longer than dentistry done in a high-volume setting.

The old adage of you pay for what you get couldn’t be more true with your teeth. My father placed crowns in the '70s and '80s that are STILL in patients' mouths today, and that’s because he had extremely skilled hands and he used highly trained dental technicians who used the best materials possible.

More information here:

Selling Your Practice to a Private Equity Firm

 

Food for Thought If Your Dentist Is Going “Out of Network”

Think of your mouth like a house that you have to live in for the next 50 years. A builder can use cheap materials and cheap labor, and your bill will be small. But if you do that with the materials that go into your mouth and you use a dentist who is rushing and might not have as much training as those of us who practice independently, you can’t just “buy another mouth,” like you can with a house.

Protect your mouth and teeth as best you can. And if your dentist tells you they are going “out of network,” be excited. It might mean you are getting amazing dental work.

What do you think? If you're a dentist, have you thought about going out of network or actually done it? What happened as a result? Comment below!

[Editor's Note: Dr. Elizabeth DiBona has been in private practice since 2008 in Seacoast, NH, and she is a third-generation dentist. This article was submitted and approved according to our Guest Post Policy. We have no financial relationship.]