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Dental Benefits Overview

Understanding your dental benefits can improve your health and lower your out-of-pocket expenses.

Choosing a Dentist

The most significant difference between a Preferred Provider Organization (PPO) dentist and a non-PPO dentist is the discount the PPO dentist gives to the patient. The discount lowers the patient's out-of-pocket costs. With a PPO plan, the patient has the option of selecting any dentist for their treatment.

In addition to the discount, PPO dentists agree to a background check of their license, previous patient complaints and malpractice history. If the PPO dentist is approved, they are accepted into the network. Non-PPO dentists do not discount their fees and do not agree to have someone review their practice information or credentials.

The differences between PPO and non-PPO dentists

The key differences between PPO and non-PPO dentists can be simplified to three elements. PPO dentist agree to discounted fees, and a review of their professional credentials and billing history. There are dentists who have good professional credentials and billing history, but who chose not to join to a PPO because they prefer not to discount their fees. The chart below highlights the key differences.

 PPO DentistNon-PPO Dentist
Discount feesYesNo
No balance billingYesNo
Approved treatment habitsYesNo
Approved credentialsYesNo

Discount fees:

PPO dentists discount their fees, which can reduce your out-of-pocket expense. Non-PPO dentists do not discount their fees. For more information see Financial Impact of Using PPO Dentists

Balance billing:

PPO dentists contractually agree not to bill the patient for the difference between the dentist's actual charge and the amount reimbursed under the patient's dental benefits plan for covered procedures. For more information see UCR Fees & Balance Billing. Non-PPO dentists can bill you for the difference between their actual charge and the amount reimbursed under your plan.

Approved treatment habits:

The dentist's treatment records are collected and reviewed to understand their treatment habits.

Approved credentials:

The dentist's credentials are reviewed, verified and approved or not approved. Examples of credentials checked include malpractice history, license status, sanctions and proof of malpractice insurance coverage.

Save money by using a PPO dentist

Preferred Provider Organization (PPO) plans offer the following financial advantages:

  • PPO dentists generally offer a 15% to 30% discount off their normal charges.
  • PPO dentists generally agree not to balance bill their patients.
  • PPO dentists have an acceptable billing practice.
  • Plan incentives to promote use of PPO dentists include:
    • waive or lower deductible for using a PPO provider.
    • higher co-insurance paid by plan for using a PPO provider.
    • higher maximum benefit for using a PPO provider.

The examples on this page are for education only. Please refer to your dental plan summary for specific information.

The following example incorporates many of the plan design incentives and an example of the potential claim savings generated by using a PPO dentist:

Type of ServicePPO DentistNon-PPO Dentist
DeductibleNone $50
Preventive services100%100%
Basic services90% 80%
Major services60% 50%
 
PPO Dentist
Non-PPO Dentist
Dentist charge for a crown$900$900
Less deductible- $0- $50
Dentist charge$900$850
Less PPO discount (20%)- $180NA
Covered charge$720$850
Patient co-insurancex 40%x 50%
Patient responsibility$288$425
Patient deductible+ $0+ $50
Total patient responsibility$288$475
Savings to patient
$ 187
 

Author: Fluent staff
Last updated: 6/30/2020
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