RANDY CURRAN
SHOULD YOU JOIN THE
IN (NETWORK) CROWD?
he landscape of Dental
T Sleep
Medicine is ever
changing. I have often
been asked by dental
practices new to sleep
medicine if they should
be in or out of network
with insurance carriers.
The first question I would
ask is “are there any in
network dental providers
near you?” If the answer
was no, I would advise
to start with an out of
network model with the
goal of obtaining a gap
approval or an in-network
exception (gap approval).
A gap approval is when
a patient can see an out
of network practice, but
be able to use better in
network benefits because
there is a gap in coverage
and the insurance doesn’t
have a contracted dental
sleep practice within
30 miles of the patients
residence.
When the practice can
successfully obtain
a gap approval, the
patient can be treated
using their lower in-
network deductible. The
practice will then have
the freedom to set their
fee at a rate that the
dentist feels is fair. This
is very beneficial when it
comes to Blue Cross Blue
Shield plans where the
contracted in network
rate is often less than
$1,400.
Being able to obtain a gap
approval and set fees at
a rate the dental practice
desires is the perfect
world. But as we all
know, we don’t live in
a perfect world. Today,
more dental practices
are moving to the in-
network billing model,
along with in network
hybrid sleep centers,
medical groups, DME
providers contracting
with dentists and oral
surgery practices. That’s
why it’s getting tougher
in many areas to get gap
approvals. With this being
said, practices may want
to start looking at going
with the in-network
billing model.
For many years, I’ve
always advised practices
to stay out of network,
but now when asked
by a dental provider if
they should go in or stay
out of network, the first
question I’ll ask is, “what
is your reimbursement
goal?” If the practice
tells me their goal is at
least $3,500 or more and
they don’t mind if they
treat only a few patients
a month, I’ll tell them to
stay out of network and
go for gap approvals.