If you are insured, regardless of the company providing you with health insurance, you should be receiving an explanation of benefits (EOB) EVERY time you use your insurance. This is an important document to review when paying your medical bills. Here’s why.

What is an Explanation of Benefits?

Your explanation of benefits tells you how your insurance provider decided to address a claim they received on your behalf. So it provides valuable information on what your insurance provider will cover in terms of the costs related to your healthcare. 

What Happens When the EOB Does Not Match Bill

The person or institution you received healthcare from usually gets their version of your EOB before you do. This is how they should determine how much you owe and send you a bill taking that into account. However, people make mistakes. So it’s important that you take a look over the statements from the healthcare provider and compare them to the EOB you received from the insurance. 

If you find a discrepancy between the two, it’s time to make some calls. I’d first call the billing department of your healthcare provider. The statement usually has their number readily available for questions about your bill. Tell them that you received your EOB and the amounts do not match. 

Most times I can fix the situation with the provider. If that doesn’t work, you’ll have to call your insurance or reach out to them via your online portal if that’s an option for you. Not loads of fun but in my experience, they are here for you. While they are limited to policy-specific rules, most of the staff I’ve interacted with try to be helpful. 

What if You Got a Denial from Your Insurance Company

Usually, there are two reasons you get a denial. Either the healthcare provider entered incorrect information on the claim OR you don’t have coverage for the care you received. 

How do you know which situation applies to you? If you receive a bill and don’t see ANY insurance adjustments and/or you never received an EOB, then it’s possible that the healthcare provider provided incorrect info. So you would want to call the provider and make sure they have your identifying information correct. If they even enter the wrong gender, insurance will deny the claim.

If the facility entered the incorrect code on the claim, you will also get denied. Finding out if this is the issue takes a little more investigating. However, if handled in a timely manner, it can be fixed.

Now about lacking coverage for the care you pursued. Now I don’t know who decided we the people are responsible for knowing all the details about our coverage but that’s a cold hard fact. I don’t know if everyone’s insurance company does this but my insurance sends me a multi-page letter at the beginning of every year reviewing my benefits. So if I “intentionally” pursue care that isn’t covered, my insurance will deny it. 

EOB Terminology You Need to Understand

The exact words might vary based on your insurance provider. I used my EOB and my dad’s to try to capture how different insurances might use different words to say the same thing. If your insurance EOB has different terms, share in the comments below. 

Date of Service or Service Date

This is the date you received care from the healthcare provider. If you received an EOB for a date where you did not receive care, you might want to reach out to your insurance company and report possible fraud. 

Charges or Amount Billed

This is the amount that the healthcare provider charges for the care they provided to you. Under no circumstances is this the amount you are going to pay. 

Discounts or Maximum Amount

So your insurance company entitles you to discounts just for being a customer of theirs. So there is a maximum amount that a provider can charge you for any particular service based on their contract with your insurance. 

So even if you have a deductible you haven’t met and your healthcare provider charges $250 for an office visit, your insurance might say the maximum they can charge you is $100. That difference of $150 goes away and the remaining $100 is subject to payment by your insurance company first. What is left is yours.

So even if you have a high deductible, insurance can come in handy. 

Insurance or (Name of Insurance Company) Paid…

This indicates how much your insurance provider paid your healthcare provider. 

Copay

Most healthcare providers require you to pay your copay upfront at the time of service. So in all likelihood, you have already paid this prior to receiving your EOB. However, if you paid a copay but your EOB indicates you shouldn’t have, you have to factor that into your conversation with the billing department of your healthcare provider.

Deductible

Your deductible is the amount of out-of-pocket costs you have to cover before your insurance starts chipping in to help you foot the bill. When choosing your insurance plan, this amount should be one that you factor in when deciding the plan you choose.

Coinsurance

Coinsurance usually kicks in after your deductible has been met. After you’ve met your deductible, your insurance usually covers a certain percentage of your bill. It is possible, though highly unusual, that your insurance would cover your bills 100% even after you’ve met the deductible. You’d have to check your benefits to see how much your coinsurance is. 

Amount You Owe or Your Total Cost

This is how much you owe. If your copay applies, then they will roll that into your total along with your deductible and coinsurance. 

Claim Number

This is SUPER useful whenever you call your insurance company. Instead of them fumbling around looking for which claim you’re referring to, you can give them the claim number on your EOB. The date of service is also useful.

How to Have a Conversation about a Billing Matter

1. Have a notepad or note app open on your phone with the relevant information you’re going to discuss. 
2. Be confident, direct, and courteous. Whatever the issue is, it’s not likely with the person who picked up the phone. Also, if you’re respectful, people will be more inclined to help you. 
3. Write the date and time along with the name of the person you spoke to. Sometimes these situations require multiple calls and you want to be able to confidently refer back to your previous conversations with other staff members. 
4. Review the key points of the conversation with the person you’re speaking with prior to ending the conversation and write them down. This assures both of you that you are on the same page.

I hope you found this post helpful in making your EOB make sense to you. If there are questions you have that weren’t addressed here, then reach out in the comment section or contact me.

While you’re here, you should find out why it’s VITAL that you have and see a PCP (primary care provider). If you are uninsured, check THIS out for information on how to get care in your area.