If you’ve used your health insurance at the doctor’s office or the hospital, you’ve likely received an explanation of benefits (EOB) in the mail.
An EOB is a document that spells out what your insurance company will pay for a doctor’s visit, a hospital stay or other medical expenses. Your EOB might look like a bill, but it’s not — even if it includes a balance saying what you owe. If you have a balance to pay, the bill will come from your doctor’s office or hospital.
So, if EOBs aren’t bills, why should you care about them?
“It’s really important that you keep a hold of the EOB,” says Caitlin Donovan, senior director of the National Patient Advocate Foundation. “We find a lot of times that billing errors where people get overcharged occur when your EOB doesn’t match your bill.”
Don’t let your next EOB get lost in a pile of junk mail. Below, we’ll walk through the basics on how to read your EOB, including the important terms to know and what to do if you catch an error.
Who sends EOBs and why?
Each time you go to the doctor or receive a medical service that is billed to insurance, your insurance company sends you an EOB. The EOB is an overview of charges for medical services, and it includes a breakdown of the amount both you and your insurer must pay the provider, according to the Department of Health & Human Services.
For patients, Donovan says, EOBs are a resource for keeping an eye on medical bills.
Each time you receive an EOB, “look it over, check for obvious mistakes and make sure it matches the bill you receive,” she says.
When will I receive my EOB?
Ideally, you should get your EOB before your bill. “Because that way,” Donovan says, “you know exactly what you should expect to pay.”
If you receive a bill and your EOB hasn’t arrived, that could mean something went awry in the billing process.
“There’s a chance the provider never billed the insurer, and you’re receiving a bill you shouldn’t have to pay,” Donovan says. If this happens, start by calling your insurance provider to ask if they processed the claim from your provider. If they didn’t get a claim, call your provider and ask them to submit one.
What should I look for on my EOB?
Every EOB contains three numbers:
- The total amount the provider or hospital charged
- The amount the insurance company paid
- The amount the patient owes
The number to pay attention to is what you owe: This is where your benefits and deductible come into play. For example, if you paid a $25 copay at your office visit, that should be reflected in your EOB. If you’ve hit your out-of-pocket maximum for the year, you may see that you don’t owe anything for your latest office visit.
If your claim was denied by your insurance carrier, your EOB will also indicate why. The most common reasons for a denied claim are that your insurance company doesn’t cover a particular service, or your insurer doesn’t recognize you as a member in their network. “Those are usually human error mistakes,” Donovan says.
What should I do if I spot an error or have a question about my EOB?
If you have a question about a service listed on your EOB — for example, an incorrect date or a charge for a treatment you never received — call your provider first to clarify the issue. Then, call your insurance company to alert them of the discrepancy.
Although your EOB lists the services you received, “they can be pretty vague,” Donovan says. If you need to take a closer look at your bill, call your provider and ask for an itemized bill that breaks down all of the charges in detail.
If your insurer refused to pay for something that you think should have been covered, follow the instructions on your EOB to file an appeal and dispute the claim.
How long should I keep my EOB?
Keep the document at least until you’ve paid any outstanding medical bills for the claims listed, Donovan says. You may want to hang on to your EOBs longer if you pay bills with funds from an HSA or FSA, in case your health spending is ever audited.
If you’re not a fan of paper documents, you may be able to pull up old EOBs through the member portal of your insurance company’s website.
Terms to know
Claim
Each time your provider bills your insurance company, they create a claim.
Date of service or date of care
The date you went to the doctor or received medical services.
Service code
A description of the services charged in a claim (e.g., office visit, immunization, hospital room and board).
Amount billed
The amount your provider charged your insurance company.
Allowed amount or negotiated amount
The amount the provider is allowed to bill your insurer; your insurer negotiates with in-network providers to determine this rate. This amount may also be referred to as “eligible expenses” or “payment allowance.”
Copay or coinsurance
If you pay a copay (a fixed amount for each visit) or coinsurance (a percentage of health costs after meeting your deductible), this will be reflected on your EOB.
Your responsibility or you may owe
The amount you owe the provider after insurance. Remember: Your EOB isn’t a bill, and if you owe a balance, you should receive a bill from your provider.
Not covered
Any charges from the provider that your insurance plan does not cover.
Reason code
An explanation for why the insurer is or is not paying the charge.
LOOK at those EOB’s and compare them to the bills you will receive as sometimes they do not match what you owe. ONLY pay when the EOB says you owe and nothing more. I am discovering that companies are trying get the patient to pay for the amount the insurance is not. Some times they rework the bill to make it look like you owe a larger amount. DO NOT be fooled. Attach the EOB to a copy of the bill. DON’T pay anything without questioning your insurance company.