Going out of network with Confidence: Strategy- Risks and Considerations

Dealing wih dental insurance companies: Bewilderness to Clarity 4

Patients file a class action lawsuit against Delta dental for misrepresenting out of network reimbursements and paying a certain percentage of their set lower proprietary fees instead of Usual and Customary fees, forcing patients to pay more for seeing out of network providers. According to another survey, Delta Dental’s (which is one of the top 10 dental insurance providers) internal fees are approximately 50% (or more) less than national average for most dental procedures. From provider’s perspective, providers are forced to be out-of-network with Delta Dental when they are not ready to negotiate reimbursements and prices. The biggest challenge of going out of network is patient attrition and uncertainty on price transparency. All the following information will be based on provider’s implications and financial impact for being an out of network provider.

In today’s dental landscape, many providers are re-evaluating their participation with insurance networks. Rising overhead costs, stagnant reimbursement rates, and increased administrative burdens have led practices to consider going out of network (OON) as a strategic move rather than a last resort. While the decision carries risks, it can also offer greater financial stability, clinical autonomy, and improved patient relationships when executed thoughtfully.

Retrieved from: https://www.deltadentalct.com/our-network-2

In the medical industry, many major hospital groups have been forced to go out of network as a group with certain insurance companies because of ongoing contract changes, administrative difficulties to get predetermination for procedures and reduced reimbursement rates. Here are some examples:

Provider / System	Type	Payer / Insurer	Year
Johns Hopkins Medicine	Academic health system & hospitals	UnitedHealthcare	2025
Brown University Health	Academic health system & hospitals	UnitedHealthcare Medicare Adv	2025
UConn Health (UConn Medical Group & John Dempsey Hospital)	Academic medical center & hospital	Aetna	2025
MUSC Health (Medical University of South Carolina)	Academic health system	Humana Medicare Advantage & Humana Medicaid	2025
Broward Health	Public health system	Florida Blue	2025
First Physicians Group (Sarasota Memorial)	Multi-specialty medical group	BCBS Medicare Advantage	2025
UTMB (University of Texas Medical Branch)(historical)	Academic medical system	Aetna (resolved by 2025)	2021

These kinds of challenges are also quite common in dental industry but not quite publicly released. But many dental offices are planning to go out of network with insurances.

Major Considerations for Going Out of Network with Insurances

Financial Implications: Case Study: A Mid-Size Practice Transition

Consider a general dental practice that performs a crown procedure with a usual fee of $1,400.

	In-Network Office	Out of network Office
Fees for Procedure	$950	$1400
Plan Pays 50%	Patient Copay: $475	Insurance pay 50% of Maximum allowable under the plan- $1000 (which comes to $500); Patient copay: $900
Provider Collects	$950	$1400

Even if some patients decline treatment due to higher out-of-pocket costs, the increased revenue per procedure can offset lower volume. Many practices find that maintaining 70–80% of their patient base post-transition still results in improved profitability.

A mid-size suburban practice producing $1.2 million annually decided to drop its two lowest-paying PPO plans, which accounted for 35% of patients but only 22% of revenue. After going out of network:

• Patient attrition will usually stabilize at 18% after six months

  • There will be many well-established patient families needing preventative cleanings where their PPO policy will still cover services at 100% so patients do not choose to change dentists despite them being out of network. Patient Experience overcasts the hassle for changing dentists and build trust all over again.

  • Many patients can afford treatments and higher copays for the quality of dental services provided

  • Hard unwanted fact- No other dentist nearby so patients are forced to see an out-of-network dentist

    
    

• Average production per patient increased by 28%

  
  

• Hygiene appointment length increased, improving care quality

  
  

• Net profit rose by approximately $140,000 annually despite lower volume

  
  

The practice reinvested part of the savings into patient education, flexible payment plans, and upgraded technology, further strengthening patient loyalty.

Administrative and Operational Considerations

Going out of network can significantly reduce administrative complexity. Practices no longer need to manage fee negotiations, downgraded procedures, or excessive documentation demands imposed by insurers. However, clear internal workflows become essential. Front-desk teams must be trained to verify out-of-network benefits, explain estimates transparently, and communicate confidently with patients.

A common mistake is underestimating the importance of scripting. Patients are far more receptive when the conversation focuses on value, quality of care, and long-term oral health rather than insurance limitations.

How to Navigate Going Out of Network Successfully

1. Analyze your data first -Identify plans with poor reimbursement, high write-offs, and heavy administrative burden.

   
   

2. Communicate early and often- Notify patients at least 60–90 days in advance. Provide written FAQs and one-on-one financial consultations.

   
   

3. Focus on value, not insurance- Emphasize clinical quality, continuity of care, advanced technology, and personalized treatment planning.

   
   

4. Offer financial solutions- In-house membership plans, third-party financing, and phased treatment options can ease patient concerns.

   
   

5. Monitor and adjust- Track case acceptance, patient retention, and collections closely during the first year.

   
   

6. PPO Fee Negotiations- Continue to negotiate with Insurances to get better fees

Risk Considerations

In many cases, a full intentional decision by a provider to go out of network isn’t the only story — sometimes it happens without clear communication, leading to surprise charges for patients. For example:

• Patients have reported cases where a doctor’s office confirmed in-network status repeatedly, only to later submit claims as out of network, leading to large surprise bills. 

• Other patients found out after care that their specialist was out-of-network despite directories showing otherwise, resulting in unexpected financial responsibility. 

  
  

While these examples aren’t provider decisions to intentionally leave networks, they reflect the real-world confusion and billing impact that occurs around network status — a key concern for any provider considering going out of network.

Retrieved from: https://fastercapital.com/content/Dental-risk-management-Mitigating-Dental-Risks--A-Guide-for-Entrepreneurs.html#Understanding-Dental-Risks

How Common Is Out-of-Network Billing — And What Protections Exist?

Frequency & Financial Impact

Out-of-network billing — where a provider is not contractually aligned with a patient’s health plan — has historically been a significant issue in U.S. health care, particularly for emergency and specialist services. Before the federal surprise billing protections took effect:

• Among privately insured patients, about 16.5 % of emergency room visits and 12.9 % of pathology servicesincluded at least one out-of-network bill. Lesser but still notable rates were found for anesthesiology (8.3 %), behavioral health (6.7 %), and radiology (4.2 %) services. These figures mean a significant minority of encounters exposed patients to potentially large out-of-network charges. 

  
  

• In inpatient settings at in-network hospitals, around 16 % of admissions resulted in at least one out-of-network charge — depending on state and specialty — even though the facility itself was in-network. 

  
  

• Out-of-network services could lead to “surprise bills” that ran into the tens of thousands of dollars, especially for surgery or ambulance transport.

  
  

These trends showed that even when patients diligently sought in-network care, elements like anesthesiologists, radiologists, or hospitalists who weren’t part of their plan’s network could leave them exposed to high costs.

Federal Protections: The No Surprises Act

To address this problem, the No Surprises Act (effective January 1, 2022) introduced strong new consumer protections for privately insured patients:

• Ban on surprise billing for emergency services — Patients must pay the same cost-sharing they would if those services were in-network, even if the provider isn’t. 

• Ban on unexpected balance billing for certain non-emergency services delivered by out-of-network providers at in-network facilities — provided proper notice and consent are given if the patient schedules the service ahead of time. 

• Limits on out-of-network cost-sharing so patient financial liability is not higher than in-network levels. 

• Requirements that providers give a plain-language notice explaining that the provider is out-of-network and what that could mean for the patient’s costs before billing at out-of-network rates. 

  
  

These protections were designed to reduce the financial blow of unplanned out-of-network expenses and ensure patients aren’t charged unexpected amounts simply because part of their care was delivered by a specialist who wasn’t in-network.

Conclusion

Sometimes being in-network with major networks leads to be at the mercy of insurance companies and be slaves of their regressive reimbursement policies. Like Delta Dental do not allow extra reimbursement for gingival irrigation medicament along with a scaling and root-planing procedure. Most of the PPO insurance companies do not pay separately for indirect and direct pulp caps along with final restorative material. These materials do come at an added cost and insurance companies unilaterally bundling services along with other bullying tactics like reducing reimbursement rates, forcing patients to pay higher copayments and other tactics should eventually be challenged to maintain an equilibrium in the market for the welfare of patients ultimately.

Transitioning from being in-network to out-of-network is not just an insurance decision but a business and clinical strategy. While it requires preparation, transparency and confidence, many dental providers find that it restores control over their practice, improves profitability and allows them to focus on delivering higher-quality care. With right planning and patient communication, one can confidently navigate the change over a period of time.

Further Reads:

1.  Traeger, S. (2022, July 22). 3 key steps for becoming an out-of-network dentist. Dentalclaimsupport.com. https://www.dentalclaimsupport.com/blog/become-out-of-network-dentist-tips

2. Securly - Geolocation sharing. (2026). Ada.org. https://adanews.ada.org/ada-news/2026/january/patient-lawsuit-alleges-delta-dental-misrepresents-out-of-network-coverage/?utm_source=chatgpt.com

3. (2022). Texas.gov. https://www.tdi.texas.gov/medical-billing/index.html

4. Williamson, A. (2023). Download: The 2023 Dental Economics Fee and Staffing Survey. Dentaleconomics.com. https://www.dentaleconomics.com/macro-op-ed/whitepaper/14299077/download-the-2023-dental-economics-fee-and-staffing-survey

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