By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"
Patient Advocate, Certified Mediator
AdvimedPro
March 16, 2024
You get EOBs from your insurance company every time a claim sent by a medical provider is processed. It is one of the most important document you can receive from your insurance. It is imperative that every patient be familiar with what an EOB is, and what it means, as their financial circumstances will be affected by this document.
A. What is An "EOB"?
"EOB" means "Explanation Of Benefits".
It is the description showing what medical service was rendered, the level of responsibility your insurance has determined it holds, and what your financial liability is.
It is also a legal contract between you and your plan, as well as between the medical provider and your plan. What is on that EOB rules, and can determine whether you owe something and how much the provider can bill you for.
B. Data you should review
1. Demographic
name of the patient, and ID# should appear
2. Provider info
who is the medical provider
is it a professional (individual) or facility (hospital) claim?
3. Service details
date of service
type of service (either general such as "surgery" or "visit") or specific (code)
4. Coverage and Benefits
Service is "covered", "pending" or "denied"
if there is an "allowance", then the claim is approved
if the allowance is $ 0.00, then a note should indicate the specific reason
5. Level of payment
This may be the most important: In or Out of Network
If "In network", you will get a discount from the medical provider, and have a lower liability
If "Out of Network", the insurance will allow less, and pay less if anything at all. You may be responsible for the full amount billed, and won't get a discount.
6. Your financial liability may be divided into 4 categories:
deductible: what you pay first before your plan pays anything
co-insurance: the % you pay while your plan pays the rest of the allowance
co-pay: the set amount you pay for a Dr's visit or ER visit
"not covered": this is a red flag. It usually means the claim was processed out of network, and that amount is your responsibility, as the plan declined to cover it.
C. Why should you care?
It's a legal document: you owe the amount indicated on the EOB ... unless...
It's a legal In Network contract: your provider must abide by it if contracted, so their bill to you must match the amount under "patient responsibility" on your EOB.
Although you have no say or advance knowledge of the rates of payment the provider and your plan have agreed to in a contract, you are held responsible for payment to that provider per the EOB
4. Errors are more common than should:
not recognizing specific circumstances, such as emergency, which might have to be processed and paid at a higher rate
ignoring State and/or Federal mandates, which force higher payments in some cases (incl. emergency conditions, services rendered at an In Network facility by an Out of Network provider, special authorization etc)
Not honoring an existing authorization
Applying the wrong rate
Miscalculating or overcharging your deductible or share of cost
5. Right to Appeal
An appeal (also called Grievance) is your right, and that of your medical provider, to request a review of how a claim was processed if you feel or know an error was made. The insurance would then have to rectify the error, and issue a corrected EOB.
How and when to file an appeal is detailed on every EOB.
Filing and winning an appeal may reduce your final liability
D. Some advice
Always reconcile every statement you receive from a medical provider with the corresponding EOB. Although "matching" amounts billed may not be correct, they are surely a red flag if they are different.
Confirm the info on the EOB is correct, especially if In or Out of Network. A provider may have billed using an OON tax ID # in error, a brand-new contracted Dr may not have their info updated in the insurance claims system yet, a special authorization may cover OON services at the In Network rate.
Double check how the claim was processed. Preventive care services at no cost to you might have been processed with an office co-pay, or denied incorrectly for non-eligibility before the system could be updated.
Examine every denied charge. Although many are legitimate and don't get paid (venipuncture with a lab, or a Dr visit for a simple covid test), others might require a call to the insurance or follow up with the provider. A coding error for example can be easily remedied.
Use your appeal rights if you suspect an error.
Charges that show a $ 0.01 billed amount can be ignored. These are reporting measures which do not affect payments or what you owe.
When in doubt, contact the provider's Billing Manager and/or the Claims Dept at your plan. Many errors can be rectified over the phone, without the need - and efforts - to file an appeal.
And if questions remain, contact a Patient Advocate specializing in Billing and insurance matters to determine what it means and what your options are.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
@martine brousse 2024 @ the medical bill whisperer 2024
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