As an out-of-network provider, you may wonder whether there are dental plans that accept assignment of benefits, allowing you to receive payment directly from the insurer. The answer isn’t a simple yes or no—it depends on the type of dental plan and the specific policies of the insurance company. Here’s a comprehensive overview to help you navigate this complex area.

1. Understanding Assignment of Benefits

What Is Assignment of Benefits?
Assignment of benefits is an agreement where a patient authorizes the insurance company to send payment directly to the provider for covered services. This arrangement simplifies the billing process and often reduces the financial burden on patients.

Why It Matters:

• Streamlined Payments: Direct payment can improve cash flow and reduce administrative follow-up.

• Patient Convenience: Patients don’t have to pay upfront and then seek reimbursement.

• Provider Efficiency: It minimizes the risk of non-payment and expedites the reimbursement process.

2. Out-of-Network Provider Dynamics

Defining Out-of-Network:
Being out-of-network means you haven’t entered into a contract with the insurance plan to accept their negotiated fee schedule. While this often results in higher fees for patients, it also provides you with more autonomy in setting your charges.

Challenges for Out-of-Network Providers:

• Lower Reimbursement Rates: Insurers may reimburse at a percentage of their usual fee schedule, leaving a balance for the patient.

• Increased Administrative Burden: You may face additional paperwork or delayed payments if the plan’s policies are not designed for out-of-network assignments.

3. Dental Plans That May Accept Assignment for Out-of-Network Providers

PPO Plans:

• Flexibility in Provider Choice: Many Preferred Provider Organization (PPO) plans allow patients to see out-of-network dentists while still offering some level of assignment of benefits.

• Fee Schedule Implications: Although you may receive payment directly, the reimbursement is often based on the plan’s out-of-network fee schedule, which may be lower than your standard rates.

Indemnity (Fee-for-Service) Plans:

• Assignment Acceptance: Indemnity plans generally allow patients to assign benefits regardless of network status. However, the patient might be responsible for paying the difference between your fee and the insurer’s allowable amount.

HMO Plans:

• Limited Flexibility: Health Maintenance Organization (HMO) plans typically require providers to be in-network. However, some HMOs may allow out-of-network claims under special circumstances, though it’s less common.

Medicaid and Medicare (Where Applicable):

• State-Specific Rules: Medicaid programs vary by state, and while they often require providers to be enrolled, some states may have provisions that allow out-of-network providers to submit claims if the patient assigns benefits. Medicare traditionally has limited dental coverage, so any assignment of benefits in this area tends to be highly specialized.

4. Strategies for Out-of-Network Providers

Verify Specific Plan Policies:

• Direct Contact: Reach out to the insurance carriers you’re interested in working with to understand their policies on assignment for out-of-network providers.

• Plan Documentation: Carefully review provider manuals or contractual agreements to identify any provisions regarding assignment of benefits.

Educate Your Patients:

• Transparent Communication: Clearly explain to patients how using an out-of-network provider might affect their out-of-pocket costs, even if they assign benefits.

• Financial Counseling: Consider offering guidance on potential reimbursement rates and any balance billing they might encounter.

Consider Selective Participation:

• Hybrid Approach: You might choose to be selective, participating in networks that offer favorable terms while maintaining your out-of-network practice for patients who seek your expertise.

• Negotiation Leverage: Even if you’re out-of-network, you can sometimes negotiate better terms on a case-by-case basis, especially if you have a strong patient base and proven clinical outcomes.

5. Conclusion

While many dental plans do offer assignment of benefits, whether they do so for out-of-network providers depends on the specific type of plan and its policies. PPO and indemnity plans are generally more flexible, whereas HMOs and some government programs may impose stricter requirements. As an out-of-network provider, the key is to thoroughly research and understand the policies of each plan, communicate effectively with your patients, and consider a selective approach to network participation. By doing so, you can optimize your reimbursement process while continuing to deliver quality care to your patients.

Benjamin Tuinei

Founder - Veritas Dental Resources, LLC
Phone: 888-808-4513

Services:
PPO Fee Negotiators | PPO Fee Negotiating | Insurance Fee Negotiating
Insurance Credentialing | Insurance Verifications

Websites:
www.VeritasDentalResources.com | www.VerusDental.com