Make sense of the information provided on your Explanation of Benefits (EOB) statements.
Kate reacts quickly to charges from an allergist.
Kate’s primary care physician referred her to an allergist for testing and a follow-up visit. After seeing the new provider, Kate received an Explanation of Benefits (EOB) statement including costs not covered by her insurance.
Kate was confused—her visit with the allergist started with an in-network referral. Using Naviguard, Kate armed herself for making some calls.
After pretty much any medical procedure, you’ll probably get something called an Explanation of Benefits (EOB) in the mail.
Many medical procedures involve services performed by providers other than your doctor, like anesthesiologists, pathologists, surgical assistants, etc. These providers often operate separately from your main provider, and they’ll bill your insurance separately. These providers are referred to as Out-of-Network (OON), and they don’t have a negotiated rate with your insurance company like your main doctor does. That’s how you can end up with a surprise bill.
A typical EOB includes:
How much your doctor or facility is charging
What’s covered under your specific health plan
Any services that were provided by Out-of-Network (OON) providers
How much you owe as part of your deductible, co-pay, and/or co-insurance
Any remaining amount which could result in a balance bill
Don’t ignore that EOB!
Even though it’s not a bill, it’s important that you go over your EOB carefully, because this info can prepare you for when a bill does arrive. Take a close look at any remarks, notes, comments, or codes, as those will give you clues about services that are considered OON.
Different facilities, different formats.
There’s no standard format for EOB documents and/or language, but all will contain the same basic information:
General service details – date, claim number, provider name, patient name
Notes ID and Remark codes – what the charge is for, what benefits were applied, approval or denial of payments. This section may also note if a service was OON.
Bill Amount, Covered Amount, and Patient Responsibility – the three main pieces of information to help you know how your benefits were applied and what you may owe.
Humans make mistakes.
EOBs are created by humans out of a lot of information, so mistakes can happen.
Here are some common issues that may cause claims to be processed as OON:
A referral was missing
An OON provider submitted a claim before your main doctor of facility did.
An emergency situation was processed as a non-emergency.
Read all those EOBs you get carefully to make sure everything makes sense and is accurate. If it’s not, call your doctor and/or insurance provider.
It’s important to go over your EOBs when you get them – and you may get several.
Your actual bill may not arrive for several months, so it’s good to check these documents when your experience is still fresh in your mind.
Health Care Math is Weird
There are a lot of figures involved in how health care services are billed, and having both In-Network and Out-of-Network providers can make things more confusing.
Here’s what you need to know:
Also called “Total Amount.” This is the amount the doctor or facility is charging for the service performed.
Also called “Member Rate.” This is the amount covered by your plan – a combination of what insurance pays and what you pay. Here’s the math:
Your applied deductible
+ Amount paid by insurance
= ALLOWED AMOUNT
This is the amount you may have to pay based on your insurance plan. Here’s how this one breaks down:
+ (Charged Amount – Allowed Amount)*
= PATIENT RESPONSIBILITY
*AKA possible “balance bill” amount for OON claims
If your Patient Responsibility total is greater than the Allowed Amount and the service was from an OON provider, you may be at risk for an OON Balance Bill.
Look for Errors!
As mentioned above, EOBs often contain errors, such as:
Incorrect OON claim
Incorrectly applied insurance benefits
If something looks off, call your insurance provider or doctor as soon as possible. You may be able to prevent a bill.
Got a Bill?
Let’s see if you need to pay the whole thing. To the Balance Bill Negotiator!