Out-of-Network Is a Myth: The Truth Insurance Doesn’t Want Patients to Hear

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We'll be in Dallas, April 22nd through 24th, 2026, or Phoenix, November 4th through 6th, 2026. For more information and to register, just click the link in the show notes. Welcome. Today, we are going to talk about a pretty hot topic.

I get questions all the time. How should we respond when a patient calls us on the phone and asks if we take such and such insurance? And there's a big concern, and I've had the exact same concern. I don't want to lie to the patient.

I want to be truthful. I don't want them to get upset when they come in. You know, we worry about all of these things. And we make the assumption that just because a patient is asking, do you take MetLife, that they are asking that in-network question.

And they are not. They want to know, does my insurance work in your office? And so I'm going to give you some words to use, some language to use that I can promise you will not be misleading, that is transparent and will help in these conversations. But first of all, I want to share a big truth bomb with you.

When we adopt the insurance company's language, we are supporting the insurance company's agenda for their profitability. Insurance companies did not create networks to help patients find dentists and to help dentists earn more patients. They created networks to help the insurance companies control fees and reimbursement rates because that's how they become profitable. The biggest advantage of networks is cost control and predictability when it comes to profit for the insurance companies.

See, when they have these networks that they've created, They can stabilize reimbursement rates, control them. They can negotiate lower fees. Anybody happen to end up with lower reimbursement rates this year? Yep, absolutely.

It steers patient flow toward where they want them to go, again, to serve their purpose and help them maintain employer contracts when they do that. So all of that helps protect their margins, does nothing for you. So in other words, basically, insurance companies are intentionally guiding patient behavior. So patients are, you know, for the most part, already primed to believe that insurance networks are determining where they should go for care.

And I mean, they've basically convinced us or done a masterful job of getting dental teams to speak their language instead of controlling the narrative ourselves. So using the term in-network, out-of-network, preferred provider, non-preferred seems very harmless. but we're just reinforcing the idea that the patient isn't controlling where they receive care, that the insurance companies pick where they get to go. And we already know that, you know, the reality is that so many patients already misunderstand how dental insurance works, and the language we choose is either going to reinforce that confusion or help correct it.

And so we don't want to unintentionally signal to patients that insurance rules get to determine in their treatment decisions. I'm gonna give you, again, some small communication shifts that I believe will make a really big difference in helping them understand their options, but really also keeping the focus where it belongs, which is on what's important to them, what they deem important, their long-term desires for their health, not their insurance plan. Now, again, let me restate this.

It's not about misleading the patient. It's about clarifying the misconceptions that their insurance companies have created. So I did a pretty deep dive into, yeah, I wanted to research and see if I could find some data that reflected what patient's general idea is about in-network versus out-of-network. And surprisingly, I found a lot of research data publications that share that information.

I'm going to put those in the show notes below. Here's one. Just kind of in summary I found an article in Dentistry Today and it said that patients often conflate out of network with expensive or not covered Here another one Dental Economics said that patients frequently assume out of network care is not covered at all, even though the majority of PPO plans still provide benefits. So again, when you're telling patients, we're out of network, but we will file on your behalf, yada, yada, yada.

Okay. They don't hear anything after the but because they've already assumed insurance is not going to work in your office. Most PPO patients, believe it or not, stay in-network even when they don't have to. National Association of Dental Plans said that more than 90% of PPO patients choose an in-network dentist.

Again, because there's a misconception that my insurance does not work if I don't go to an in-network dentist. And so, you know, that whole behavior gap reflects the misconception with patients that believe they have to stay in network, assuming insurance isn't going to pay anything otherwise. So again, you know, we have to understand this is all about profitability for the insurance companies, but they do a really masterful job at disguising it as benefits to the patient. And I'll share a little bit more reinforcement for that here in a minute.

But you have to remember this whole concept of in-network, out-of-network was created by the insurance companies to benefit them. If that's not enough evidence or if I haven't convinced you enough to stop using, keep listening. To stop using that language, keep on listening. I just want to make sure we're not reinforcing the insurance authority because patients already, because of the medical model, believe that they have to, that insurance companies determine where they get to go.

And in doing that, you know, all the conversations we have are more around insurance rules instead of what the patient wants to accomplish. And so, So, you know, that's why I say when a patient calls on the phone and say, you know, they ask, do you take Delta Dental and you're not on that restricted list? You know, the tendency and what I hear so often in phone calls is you'll immediately go to, well, we aren't in network, but we'll file on your behalf or whatever. But we want to make sure we're focusing on the connection first.

So patient calls, do you take Delta Dental? Absolutely. We have a lot of patients that have Delta. Do you mind me asking your name?

sounds like you're looking for a dentist. Tell me a little bit more. Now, I know that scares a lot of you. And so just hang tight for a minute because I want to make sure that we're not misleading.

So, you know, again, rather than saying we are out of network with your insurance, try this. Dr. Brady's actually an independent provider for Delta. You won't find his name on your restricted list.

But the good news is you don't even have to choose from that list to use your dental plan. In fact, we have a lot of patients with the same plan. If they require or ask for more explanation, I would say, hey, go check out the website for your plan. And actually, you'll see there's, you know, likely a chart for in-network and out-of-network, the language they use.

And you'll see that the maximum, the deductible, the percentages are all the same. You know, and if they ask, you know, am I going to need to pay more? Yeah, you're out of pocket. In some cases, maybe slightly more.

And in other cases, it's not. But again, remember, your maximum is still the same. The good news is we're going to help take care of all the paperwork and always work to maximize that reimbursement so you don't have to worry about it. Here's something that really, this was kind of the motivation for me to record this podcast.

Someone sent over this letter that one of their patients had received. And the insurance companies that send this letter out call it their out-of-network warning letter, if you can believe that. And so when they notice that a patient is seeing an out-of-network provider, they send this letter to them. Now, not all carriers, but the majority of them do.

I know Delta does. I believe MetLife and I think Cigna are the ones I know of for sure. But let me read this letter to you. You'll get your blood boiling here.

Our records indicate that you recently visited or scheduled an appointment with Dr. So-and-so, who is not a participating provider in your dental plan network That in big bold letters Choosing an in dentist however can help you maximize your benefits and decrease your out costs Participating dentists in our plan have agreed to our contracted fees and billing standards that are designed to save you money. When you receive services from an out-of-network provider, here's what's happening.

Your dentist is likely charging higher fees than the plan's allowed amount. Your plan may pay a lower percentage of that cost As a result, you may be responsible for additional charges beyond what your plan covers. The provider will likely bill you directly for the difference. To reduce your costs, we encourage you to consider seeing a dentist in your network.

Here is a list, it's a link, where you can find a participating provider near you. If you've already scheduled treatment with this out-of-network dentist, we recommend confirming the expected costs and always seek alternative providers before proceeding. I mean, really? That's ridiculous.

I believe that's manipulative. I believe it's misleading. I mean, that is way more manipulative or misleading than anything we are ever trying to do in helping patients understand the reality of insurance. Now, again, if that doesn't get you going, let me share this letter.

This is a letter from Delta specifically that went to a patient after their dentist went, quote unquote, out of network. We want to inform you that Dr. Blank will no longer participate with Delta Dental of Texas as of, and it has a date. This means your Delta Dental benefits will no longer cover you at the same level if you continue to see this dentist after this date.

Some of the most important benefits of seeing a Delta Dental participating dentist are discounted fees. Delta Dental payments are sent to participating dentists, so you don't need to worry about paying up front for expected Delta Dental insurance reimbursements. You also get protection from balance billing, and they have in parentheses, being billed the difference between Delta's discounted fees and the dentist's regular fees. Protection from unbundling.

This is a billing practice where one procedure is broken down and billed as multiple procedures, increasing the cost to the patient. Protection from other types of billing that can cause increased costs to patients. This protection, they're protecting the patient. This protection can occur because participating dentists are required to honor Delta Dental claims processing policies, saving you money.

And then it does, you know, it does say here as a Delta member, you do have the freedom to visit any licensed dentist. but then in big bold letters. However, you receive the greatest benefit coverage when you see a Delta Dental participating PPO provider. We have nearly 3,000 locations and, you know, the state of Texas, you can search for a Delta Dental PPO dentist near you by clicking this link.

When you choose a Delta Dental PPO dentist, you pay less out of pocket and get more coverage. Your benefits go further. So again, this whole in-network, out-of-network is a manipulative practice, I believe, by the insurance companies to manage contracts and influence patient behavior. Do not allow the insurance companies to control that narrative to your patients.

You need to control the narrative. And when you can do that in a way that's clear, neutral, I'm not saying bad mouth the insurance companies. That's not where I'm going. But in a neutral, clear way that emphasizes the patient's choice, their care, what's important to them.

You know, it's going to help them better understand, hey, insurance is great. It's wonderful that you've got, you know, this plan. A lot of patients found it's pretty much kind of a rebate or a stipend. You know, that's a thousand dollars toward your care, whether you go to someone on your list or not.

You get to decide. And I think it's important for them to understand that. Now, I have got several different resources that I'm going to put in the show notes and want to share those with you. So be sure you click on those because you're going to get lots of different language, lots of other ways to respond to this question.

You know one of the questions I get quite often is do we need to warn patients that we out of network I get it I been in that seat where I want to be black and white I don want there to be any confusion I don't want anybody to be mad at me. And, you know, I had a situation a while back where I sent over a few new patient phone calls and she said, will you help me figure out how to improve these conversations so that I can convert more new patients? Because we're getting calls, but not many are wanting to come in.

And so I had the opportunity to listen to several of these calls with her. And this first or second, oftentimes the first question she was asking was, do you have insurance? And if the patient responded, yes, they did have insurance. For example, the patient might say, yes, I have Delta.

And she said, oh, well, we're not Delta preferred providers, but we can still see you. And that created a lot of confusion. And she said, you know, in most cases, they're not scheduled and so on. So first thing I told her, I said, do not bring up insurance.

Let's make sure we're not making that our first or second question. Even if the patients call and say, do you take such and such? Again, like I said earlier, we want to connect first, get their name, get their story. And, you know, you'll see sample conversation in the resources below.

Initially, she was resistant. She said, I tried that last year when we went out of network and had a lot of patients come to the office that were really upset that we weren't in network. so I want to warn them on the phone before they come in and I'm like oh my gosh and so as we continue to talk through this you know and I asked the question I said how many patients got upset when they found out doctor was not a participating provider and how did they find out and she said well you know I told them like okay so again we're bringing the attention to that when they come into the office and so she said you know and then they wanted to know well why didn't I tell them on the phone and this and that and the other.

And she said, I tried to explain. I said, well, again, we're leading with this, you know, we're not a network thing, which is not helpful. And so see what's wrong with this picture. I mean, it's, it just doesn't go well.

And so we want to make sure that not, we're not an obstacle, that we're not getting in the way. First and foremost, be really cautious of imposing your value system on the patient. I remember thinking, wow, I, you know, And this is when I was, you know, my husband and I had bought our first house. We had a baby.

We didn't have hardly any discretionary income. And in my mind, I'm thinking I wouldn't want to go to anybody that wasn't in network. And so that no doubt was influencing my communication. And so, you know, we've got to be we've got to be careful that we're not imposing our value system on other patients.

And so let's be cautious with this. And if they say, well, if I have known you were out of network, I wouldn't have come. Why didn't you tell me? Well, my response to that would be, you know, I know that can be confusing.

And, you know, we've actually discovered that a lot of patients think that out of network means you don't get any coverage at all. And that's not true at all. In fact, we've got a lot of patients on this plan. They don't notice much of a difference.

Their maximum's the same. Again, be careful with how we're handling this. So anyhow, take a look at those resources below. And I appreciate you taking time to listen to this conversation.

I believe it will make your phone calls and your patient relationships much better. Did you know that Brady Group offers personalized coaching for you and your team? Through your own personal practice guide, we can help get more of what you want. More time with your family, more case acceptance, more money, a more cohesive team, more peace.

We do not believe in cookie cutter coaching. Not only will you have access to our systems, resources, training tools in lots of different formats, you're going to get the customized support of a personal guide to assist you in applying those materials in a way that ensures success in your unique practice. As an all-access member, you'll never pay tuition or additional fees for events or resources. Check out the link in the show notes for more information on our month-to-month coaching program or call me directly, 800-592-7239.

Again, call Amy at 800-592-7239.