“In-network” and “out-of-network” are two of the most used, and most misunderstood, phrases in your practice, by patients and sometimes by staff. Patients often hear “out-of-network”" as “they don't take my insurance,” which is usually false. Owners describe themselves as “a PPO office” or “fee-for-service” without always being precise about what that means for billing, patient cost, and who actually gets paid. And it matters more than ever: in a late 2025 ADA Health Policy Institute poll, more than half of dentists named insurance, low reimbursement and delayed or denied payments, as a top concern heading into 2026. This piece clears up exactly what the two network statuses mean, how money moves in each, and what each model means for running a practice.

The two statuses, defined

In-network (participating): You’ve signed a participating provider agreement with the plan and agreed to its contracted fee schedule. You’re listed in the plan’s directory, the patient receives their highest level of benefits when they see you, and you write off the difference between your full fee and the contracted fee.

Out-of-network (non-participating): You have no contract with that plan. You bill your full fee. If the patient’s plan includes out-of-network benefits, the plan still pays its share — reimbursed against its out-of-network allowance — and the patient covers the rest. You aren’t bound by anyone’s fee schedule.

Two things to hold onto. First, network status is per plan: the same practice can be in-network with some plans and out-of-network with others at the same time. A “fee-for-service practice” is simply one that’s out of network with most or all plans; a “PPO practice” participates in one or more. Second, the entire difference between the two comes down to a single question: who absorbs the gap between your full fee and what the plan pays? Which we’ll come back to.

The misconception that costs you patients

Here’s the one to train your team on immediately: out-of-network does not mean “we don’t take your insurance.” An out-of-network practice can absolutely treat insured patients and file their claims. If the patient’s plan has out-of-network benefits, the plan pays its share — most commonly a percentage of the usual-and-customary allowance — and the practice simply isn’t held to a contracted fee schedule. The patient may pay more out of pocket than at an in-network office, but they are not uninsured at your practice. When “out of network” is allowed to land as “they don't take my plan,” you lose patients you never needed to lose.

The exception worth flagging: some plans, many DHMOs and exclusive-provider (EPO) designs, have no out-of-network benefits at all. For those patients, seeing an out-of-network dentist genuinely means no coverage. Knowing which of your patients’ plans fall into that category is essential for honest estimates.

How the money moves: assignment of benefits

This is the mechanic that trips up out-of-network practices, and it’s worth understanding precisely.

When you’re in-network, the contract requires the plan to pay you, the practice, directly. You collect the patient’s portion, deductible and coinsurance, from the patient, and the insurer’s portion from the insurer. Clean.

When you’re out of network, the default is murkier: the plan may send the reimbursement check to the patient rather than to you, which leaves you collecting the full amount from the patient and hoping they forward what the insurer paid them. The fix is assignment of benefits — the patient’s instruction directing the plan to pay the dentist instead. On the 2024 ADA Dental Claim Form, the subscriber’s signature in Box 37 authorizes the plan to send payment directly to the dentist, and that authorization only directs where the payment goes — it does not create a contract with the insurer or change the patient’s financial responsibility.

Whether the plan must honor that instruction depends on your state. As of mid-2024, roughly two dozen states had enacted assignment-of-benefits laws requiring plans to pay the dentist directly when the patient authorizes it, regardless of network status, and more have been added since. But there’s a catch even where those laws exist: self-funded employer plans governed by the federal ERISA law may claim exemption from state insurance statutes and pay the patient anyway. Since many employer plans are self-funded — and you usually can’t tell from a patient’s card whether a plan is fully insured or self-funded — an out-of-network practice should set a clear policy: collect in full up front, or use assignment of benefits and verify how that particular plan handles it.

What the patient actually pays

Cost is where patients feel the network difference, so set expectations before treatment, not after.

In-network, the patient’s deductible and coinsurance are applied to the lower contracted fee, and you cannot bill them beyond it. Their cost is lower and predictable.

Out of network, two things change. The deductible and coinsurance are applied to the plan’s out-of-network allowed amount — often a UCR figure, which (as we covered in our UCR issue) the carrier sets and rarely discloses. And out-of-network coverage frequently carries a separate, higher deductible and a lower coinsurance percentage. On top of that, the patient may owe the balance between your full fee and that allowed amount. The result is a higher and less predictable out-of-pocket cost, but if your full fee sits close to the plan’s allowance, the gap can be modest. One useful note for patients: out-of-network dentists may receive explanation-of-benefits statements that appear to impose a fee limit even though no contract exists. That “limit” is just the plan’s allowance, not a cap on what you may charge.

Balance billing: the rule that defines the divide

If you remember one thing, remember this. In-network, you cannot balance bill — the write-off is mandatory, and you collect only the contracted fee, split between insurer and patient. Out of network, you generally can bill the patient your full fee, subject to your state’s law, and the patient owes whatever the plan doesn’t cover. Who eats the difference — the practice, in-network; the patient, out-of-network — is the cleanest way to understand the two models.

What it’s like to run each kind of practice

The in-network practice runs on volume. The upside is real: directory visibility, a steady flow of patients steered to you, lower patient out-of-pocket that eases case acceptance on price, and the simplest possible message — “yes, we take your plan.” The cost is the write-off on every procedure, fee schedules you don’t control, heavier administrative work (claims, denials, plan rules, utilization review), and thinner margins that demand higher volume. In-network practices compete partly on being listed and on price.

The out-of-network practice runs on fees. You set and collect your full fee, keep more margin per patient, live under fewer plan rules, and tend to attract patients who chose you for the relationship rather than the discount. The trade is that you have to communicate and justify your fees clearly, manage the assignment-of-benefits and collections friction above, and generate your own new patient flow through reputation and marketing rather than relying on a plan’s directory. Out-of-network practices compete on relationship, experience, and perceived value.

Most practices live in between

You don’t have to be purely one or the other, and most aren’t. Network status is a per-plan decision: you can participate in a few strong plans and stay out of network with the rest, and you can change one plan’s status without touching the others. (How to decide which to keep is its own question — what we think.) The practical point is that “in-network” and “out-of-network” describe individual relationships with individual plans, not a fixed identity for your whole practice.

Putting it to work

A few habits keep network status from becoming a source of confusion or lost revenue:

In-network versus out-of-network comes down to one trade you now recognize: in-network, you accept a contracted fee and can’t bill the patient the difference; out of network, you keep your full fee, but the patient — and your front desk — absorb more, including the question of who the insurer pays. Neither status is inherently right, and most practices live on a per-plan spectrum between them. Understand the mechanics, communicate them clearly to your patients, and review the details with your dental CPA, and network status stops being a source of friction for everyone involved.