Sometimes, insurance companies elect to pay for the least expensive procedure if there is more than one acceptable option for treatment. This is known as a “downgrade”, and it can present its own unique issues to both the patient and the dental team members. If patients choose the more expensive option between the two, they will be required to pay the difference out of their own pockets.
A common example of something that is downgraded is fillings or crowns: insurance companies might elect to pay for the cheapest option, which would be the amalgam (silver/ mercury) filling over the composite or resin filling, or the all-metal crown over the all-porcelain crown if the crown is being placed on one of the patient’s posterior teeth, or molars.
Insurance companies might elect to downgrade a procedure regardless of being in-network or out-of-network. The patient will be charged for the difference in price directly.