By: Ellen Kondora, Benefits Account Manager - Austin
You’ve been having abdominal cramps for a few days and decide to see your family doctor. She orders blood work, along with a CT scan. All of the providers are in network, so you’re not too concerned about the cost. A few weeks later, the bills start rolling in—one from your primary care physician, another from the lab, and another from the diagnostic center. Now you’re confused. Which ones do you pay? Do you have to file a separate claim with your carrier for each invoice? And, how do you know which healthcare providers already have been reimbursed?
The answers can be found in your Explanation of Benefits (EOB), the letter that you receive from your carrier that lists all covered expenses and how much is your responsibility. The EOB generally arrives 4-8 weeks after your medical service. The top portion will state clearly "THIS IS NOT A BILL"; however, many people don’t realize that they should wait to receive the EOB before making any payments to their doctor or other healthcare provider. That’s because the Explanation of Benefits provides a detailed overview of the total charges for your visit, how much has been paid by your carrier, and how much you may owe. Without referencing the EOB, you could end up overpaying on your medical bills or overlooking important information about your coverage.
Reading the EOB
Insurance providers use different formats for their Explanation of Benefits, and some can be difficult to interpret. In general, the EOB is broken into several main content areas:
Knowing When to Pay
To ensure that you are not overpaying for medical services, you should set aside all bills that you receive from your healthcare providers until the Explanation of Benefits arrives. Then, compare each bill with appropriate entry on the EOB to confirm whether the provider has already been paid, and the actual amount that you owe. Doctors and laboratories often send a bill before the claim has been processed. If the amount listed on the healthcare provider’s bill is more than what is on the EOB, pay the amount that the EOB shows you owe, and include a photocopy with a note in the margin that you are paying the amount specified by your insurance carrier.
Of course, insurance carriers can be slow in processing. If you get a second bill, call your doctor’s office and explain that you haven’t yet received your Explanation of Benefits. As an in-network provider, they are obligated to wait for that EOB, as well. On the flip side, if you already paid a bill from a doctor or hospital and then receive an EOB showing that your carrier covered some or all of the expense, you can ask the healthcare provider for a refund. Contact your provider’s billing department and ask how to send a copy of your EOB to request a refund. The provider gets a copy of the EOB, too, and may proactively send a check, but usually, they wait for you to request a refund.
Asking for Help
Many people do not look at the reason code to understand why a charge was not covered, which can leave them confused about what they owe. Excluded amounts almost always represent the in-network discount; however, the charge also may not be eligible for benefits under the plan. If you believe that a claim was denied in error, contact your insurance broker to find out exactly how the charge was coded. All claims are processed based on ICD-10 diagnostic and procedure codes, and claims that were denied sometimes are the result of a coding error made in the physician’s office. If you feel that a service was coded incorrectly, you may need to contact your healthcare provider and request that their billing office correct the coding and resubmit the claim.
In other cases, you may have paid a copay at the time of service, and later received a bill from the healthcare provider. If your EOB shows that you do not owe anything, call the provider’s customer service number on the billing statement and explain that according to your Explanation of Benefits, you have already paid the amount you owe. It is not uncommon for healthcare providers to attempt to bill patients the difference between their customary charge and the covered amount based on their contract with the carrier, but in-network providers are legally bound to the contractual discounts that they agreed to for that insurance plan.
The entire billing process can be even more complicated for in-patient hospitalizations. Although you might expect to be charged for the surgeon and the facilities, you may not even know that you also will receive a bill from the anesthesiologist or the surgeon’s assistant. If these charges are not included on your Explanation of Benefits, they may not have been submitted to your carrier, and you may need to file a claim separately. Always question charges of which you were not aware, and call the hospital or healthcare provider to find out whether bills already have been submitted to your carrier. In some cases, your insurance provider may deny the claim; for example, if the carrier believes that the expense should be included as part of other covered fees. If you feel you are being charged in error or that a claim has not been processed correctly, contact your insurance broker or the service team assigned to your account to ask for help.
You should keep all previous EOBs on file, because months or even years down the road, a provider could send a bill and claim that you owe money. Although healthcare providers receive the same EOB that you do and already know what you owe, they may try to bill the difference between their standard charges and the amount the carrier will cover. Fortunately, they cannot force you to pay under the terms of their contract as an in-network provider. If you get an erroneous bill and the claim has already been processed, contact your provider and ask where to send your EOB and a record of what you already paid, to prove that you don’t owe anything on the account.
Overall, be sure to set any bills from healthcare providers, diagnostic centers or laboratories aside until you receive the corresponding Explanation of Benefits from your insurance company. If a bill arrives for which you don’t have an EOB, you can check whether the EOB is available through your plan’s online member portal, or call your insurance company and explain that you received a bill from the provider for the specific date of service and have not yet received an EOB. The representative will say that either the claim hasn’t yet been processed or the carrier is waiting for additional information from the healthcare provider. If the claim was processed, the carrier can mail you another copy of the EOB. Once you receive the letter, be sure to keep a copy on file and attach it to all the other bills that come in associated with that claim. The EOB should be treated as a legal document and kept on file as it provides an accurate record of what you owe, if anyone tries to bill you for those services.