Why Review Your Health Plan’s Explanation of Benefits

Have you ever been surprised that you owe for a medical procedure because maybe you thought your insurance paid the entire amount? In fact, so surprised that you handle it by ignoring the multiple statements, phone calls and the explanation of benefit statement from your health plan (which is where it all begins)?

What’s on an EOB?

Healthcare insurance providers are required by law to send a copy of the EOB to their patients. It can be labeled as a medical claim summary or medical summary notice as well as an explanation of benefits. Usually, in noticeable lettering, it will read: This is not a bill.

Some of the information that will be on it includes:

  • The name of the provider
  • What services were provided (blood test, wound treatment, physical therapy, etc.)
  • The amount your provider charged for your treatment
  • The amount that the insurance company will pay, usually referred to as amount allowed (also called allowed charges, negotiated amount or allowed amount)
  • Any co-pay you made
  • The amount you will have to pay after you have met your deductible (coinsurance)
  • The amount of the charges that your insurance company will pay
  • The difference between what the insurance company will pay and what you were charged by your provider, also called not covered, not payable or pending. This is also the amount that you may be billed for.

Below are important tips to remember when reviewing these statements:

EOB Dos:

  • Keep your EOB and when you receive your bill, compare them. They should match.
  • Respond immediately to requests for information.
  • Review the services you received and the dates they were performed to guard against billing fraud and identity theft.
  • Check the coverage information section so you know exactly treatments that were or should be covered.
  • Scan for double billing which can occur if more than one treatment or provider was used.
  • Ensure your health plan benefits were correctly applied.

EOB Don’ts:

  • Ignore the EOB statement because it is not a bill. It is the foundation for the bill and deserves careful scrutiny.
  • Be afraid to question anything that you are uncertain about.
  • Fail to pursue any errors. Most healthcare insurers have numbers you can call to begin any dispute process.
  • Forget to compare the EOB against the bill.
  • Avoid educating yourself on all aspects of your medical life which is with you forever.

Many patients ignore the important information contained in this document. Take responsibility for understanding the ins/outs of your health insurance plan or if you do not have one, ask questions upfront to prevent surprises. Understanding the EOB can help keep you out of collections!