Dear ADA: Out-of-network billing

Documentation, communication help set appropriate expectations for patients

Dental insurance issues are often cited as one of dentists’ biggest challenges.

In response to an ADA Health Policy Institute poll in late 2025, more than half of dentists reported that one of their top concerns looking ahead to 2026 was related to insurance, including low insurance reimbursement rates and delayed or denied payments.

This ADA News series aims to address some of those challenges. “Dear ADA” will feature answers to common insurance-related questions the American Dental Association receives from members to help provide clarity and direct members to additional resources.

The answer to this month’s question is provided by Lindsay Compton, D.D.S., a member of the ADA Council on Dental Benefit Programs.

Dear ADA: As an out-of-network dentist, I sometimes receive explanations of benefits that appear to impose fee limitations or indicate little to no patient responsibility despite the absence of a contractual agreement. How can I address these situations while helping patients understand their financial responsibility and protecting my practice from payment challenges?

Dr. Compton: When an out-of-network explanation of benefits, or EOB, appears to impose fee limitations or shows little to no patient responsibility despite the absence of a contractual agreement, dentists should focus on three priorities: addressing potentially inaccurate benefit determinations, clearly communicating financial responsibility to patients and using consistent office policies to reduce payment challenges.

If an out-of-network EOB shows patient responsibility as $0 even though the payer has not paid the dentist’s full fee or has applied fee limitations, the EOB is incorrect and should be challenged. The ADA is a valuable resource for dentists when having to deal with these types of issues.

It is important to remember that in an out-of-network situation, the patient “benefits” relationship is with the payer, not the dentist or dental office. The dentist is entitled to their full fee as remuneration from the patient. At the same time, many patients have out-of-network benefits, and it should be clearly communicated that they are still welcome to receive care at your office.

When it comes to communicating financial responsibility with the patient, there are some key points that should be considered. Firstly, offices should start by recognizing that most patients misunderstand their out-of-network benefits. Patients often assume that the financial payment works the same as it does in network. Furthermore, others mistakenly believe they can only see an in-network dentist.

It is imperative that the dental office team clearly communicate the practice’s network status, provide patients with a written financial policy, and explain that while the office may submit claims as a courtesy to help maximize available benefits, the patient remains responsible for the balance. Having patients sign acknowledgements confirming they understand these expectations can help reduce confusion and disputes.

All of these communications should occur prior to treatment and as a best practice, during the intake process.

When communicating with the patient, it is also imperative to stress the importance of their care and the expertise you provide. Because out-of-pocket costs may be higher, this emphasis will help encourage the patient to understand the value of their care outside of “doing only what insurance covers.”

While a pretreatment estimate is not a requirement, it is especially helpful for the patient so they may understand their financial responsibilities.

For an out-of-network dentist, the estimate should be based on the dentist’s full fee. When available, information regarding deductible, co-insurance and other processing policies that may impact final payer reimbursement may be included and explained to the patient.

At the same time, it should be clearly communicated that the estimate is provided as a courtesy, is based on information supplied by the insurance company and is not a guarantee of coverage or payment. The estimate should also clearly indicate the patient remains responsible for the office’s full fee, even if the office is willing to wait until the third-party payer adjudicates the claim. It is also prudent to explain that while the office will provide necessary documentation for an appeal, it will be the patient’s responsibility to settle any disputes regarding payment by their insurance carrier. In addition, the office may wish to inform the patient that all outstanding fees are due, even when the claim is being appealed by the patient.

Out-of-network dentists may wonder if they can receive payment directly from insurance plans. When a dentist submits an out-of-network claim on behalf of the patient, Box 37 on the 2024 ADA Dental Claim Form requires the policyholder’s/subscriber’s signature and date (or a “signature on file” notation) to authorize the insurance plan to send benefit payments directly to the dentist. This authorization applies only to the direction of payment. It does not create a contractual relationship between the dentist (or dental entity) and the insurance company, nor does it alter the patient’s financial responsibility.

In some states, dentists have additional protection. As of July 2024, an estimated 23 states had enacted laws requiring dental insurance plans to honor a patient’s request to send payments directly to the dentist when the patient has authorized it. Dentists should review ADA materials addressing assignment of benefits and work with their state dental societies to place or enhance these protections within their states.

In summary, successful management of out-of-network payment challenges depends on consistency: clear financial policies, accurate pretreatment communication, documented patient acknowledgements and proactive communication about insurance limitations. These steps help patients better understand their financial responsibility while reducing payment uncertainty for the practice.

When in doubt, ADA members can contact the ADA Third Party Payer Concierge for complimentary help resolving dental insurance questions or issues. Members can reach the concierge by email at dentalbenefits@ada.org.