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Explanation of Benefits (EOB), Explained

There are many terms and abbreviations in the world of health insurance that can be hard for patients understand. If you’re confused, you’re not alone. Our aim is to bring clarity—AND help you manage your out-of-network health care costs.

What does EOB mean?

EOB stands for “Explanation of Benefits.” Ok, so what is an EOB? After you’ve gone to a doctor or had a medical procedure, you usually get an Explanation of Benefits in the mail from your insurance company. In fact, you may receive more than one Explanation of Benefits, even if you only had one event or procedure—because separate EOB’s can come from each provider, service or facility involved in your treatment.

A typical EOB tells you:

  • General service details – the date of the service, the claim or reference number, the name of the doctor/provider you saw, your name
  • How much your doctor or the facility is charging, and what each charge is for
  • What’s covered by your insurance plan—and specifically, how your insurance benefits have been applied
  • The bill amount, the amount insurance covers, and the “patient responsibility”, which is the amount the provider expects you to pay for the service. These three pieces of information are key to understanding what you actually owe.

 

Is an EOB a Bill?

An Explanation of Benefits is NOT a bill, it’s a recap of how your insurance company is processing a claim from a provider. You will likely see a bill from your provider soon, and unless they apply additional discounts, the amount listed as “patient responsibility” is what you will be asked to pay.

 

Why should I look at the Explanation of Benefits if it’s not a bill?

It’s important to go over your EOBs carefully when they arrive. By reading them now, while the experience is still fresh in your mind, you can ensure that everything’s accurate and there’s nothing unanticipated…now, or when the bill comes.

 

A potential EOB pain point: out-of-network providers and charges

Sometimes, medical procedures involve services performed by providers other than your doctor—like anesthesiologists, pathologists, surgical assistants, and more. These providers may operate separately from your main provider, and they’ll bill your insurance separately. They’re referred to as out-of-network-providers—which means they don’t necessarily have standard, negotiated rates with your insurance company like your in-network care providers do.

If you receive an Explanation of Benefits that includes out-of-network charges that appear to be excessive, it might be a mistake with a fairly simple explanation—like:

  • A referral from your doctor for another provider/specialist/service was missing
  • An out-of-network provider submitted a claim before your main doctor or facility did.
  • An emergency situation was processed as a non-emergency.

 

There are some legitimate reasons for out-of-network charges, too.

But whether the out-of-network charges are correct or not, getting clobbered with a big number you didn’t expect can be distressing. Don’t panic. We’ll help you get to the bottom of it.

 

In EOB hot water?
Turn To Naviguard.

We created Naviguard because health care costs can be incredibly confusing—and expensive. One in five insured adults has received an unexpected bill from an out-of-network provider. Our job—our sole focus—is to help resolve just such issues and prevent them in the future. We are health insurance experts and experienced negotiators who work on behalf of plan members in a Naviguard participating plan. And in almost 90% of cases when a member is balance billed and engages with Naviguard, we’re able to reduce the amount paid for the out-of-network services .[1] If your health plan is a Naviguard participating plan, our services are included at no charge as part of your employer’s plan.

Put our expertise to work. We’re here for you.

 

[1] Based on actual Naviguard results from 1/1 – 7/31/2021. Individual results may vary and there is not guarantee Naviguard will be able to reduce your bill.