(Note that if you’re enrolled in Original Medicare, you’ll receive aMedicare Summary Noticeinstead, which is similar but not the same thing as an EOB. However, if you have a Medicare Part D plan orMedicare Advantagecoverage, they will send EOBs.)
Depending on the circumstances, your insurer may or may not have paid some or all of the charges—after thenetwork-negotiated discount—and you may or may not be receiving a bill for a portion of the charges.
Your EOB should clearly communicate all of this, but sometimes the information can feel overwhelming and it’s tempting to just stuff EOBs in a drawer without looking at them, especially if you’re dealing with a complex medical situation in which you’re receiving numerous EOBs.
But your EOB is a window into your medical billing history. Review it carefully to make sure you actually received the services for which a claim was submitted, the amount your healthcare provider received, and your share of the bill are correct, and that your diagnosis and procedure are correctly listed andcoded.
Practitioners’ offices, hospitals, and medical billing companies sometimes make billing errors. Such mistakes can have annoying and potentially serious, long-term financial consequences. An EOB can also be a clue tomedical billing fraud. Your insurance company may be paying for services billed on your behalf that you did not receive.
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Examples
Double Billing
Mary J. visited her primary care physician (PCP) and had a chest X-ray because of a chronic cough. Her PCP sent the X-ray to a radiologist to be read.
The following month Mary got her EOB and a bill from the radiologist. When she looked at her EOB she noticed that both her PCP and the radiologist billed her insurance company to read the X-ray. The insurance company rejected this claim from the PCP—although they paid the PCP for the office visit—and only paid the radiologist for reading the X-ray.
In this case, Mary’s PCP’s office might catch the mistake and delete the billed amount. But it’s also important for Mary to pay attention to the bill she receives from the PCP’s office, to ensure that they haven’t passed on the charges to her after the insurer rejected the bill.
Miscalculating Your Coinsurance Amount
Robert M. had outpatient surgery on his hand. He is in aPPOand he pays acoinsuranceof 20% for outpatient procedures (we’ll assume he’s already met hisdeductiblefor the year).
Robert did the math and figured that he should be paying $600 instead of $1,000, since he should only have to pay 20% of $3000, not 20% of $5000. His health plan confirmed that was correct and Robert was able to pay out $600 instead of $1000.
As long as patients use in-network facilities and healthcare providers, their coinsurance amount is always calculated based on the cost that’s allowed under the health plan’s agreement with the provider, NOT the amount that the provider initially bills. And theNo Surprises Actprotects patients from out-of-network billing in certain situations where the patient didn’t have a choice to use an in-network provider.
Wrong Diagnosis or Procedure
Zahara very wisely called her health plan and practitioner’s office to correct the diagnosis error to ensure that all parts of her medical history were accurately recorded.
Her healthcare provider resubmitted the claim with the correct code and the insurer reprocessed it. Since a throat culture and a diabetes test might have very different pricing, Zahara waited until the second claim had been processed before sending any money to her practitioner’s office for her coinsurance.
Health Plan Error During Claim Processing
Fortunately, Leandra knew that ACA rules require her health plan to cover recommended vaccines without any cost-sharing, which means the patient doesn’t have to pay a deductible, copay, or coinsurance (this is true for the vast majority of all health plans, but not for grandfathered plans or plans that aren’t subject to ACA regulations, such asshort-term health insurance).
She contacted her health plan, notified them of the error, and asked them to reprocess the claim. She also reached out to the doctor’s office and asked them to make a note in her file about the claim being reprocessed. A few weeks later, Leandra and the doctor’s office received new EOBs indicating that the claim was being paid in full, and the doctor’s office confirmed that they had received payment from the insurer and Leandra did not owe any money.
Insurance Fraud and Medical Identity Theft
Aside from having well-controlled high blood pressure, Jerry R. is in excellent health and enjoys playing golf in his Florida retirement community. He is enrolled inOriginal Medicareand visits his healthcare provider two to three times a year.
Jerry received aMedicare Summary Noticeindicating that he had received a wheelchair, hospital bed for home use, and a portable machine to help him breathe.
Jerry called his healthcare provider’s office to confirm that his practitioner had not wrongly billed for another patient. The nurse in his practitioner’s office told Jerry this was most likely Medicare fraud and she gave him a fraud alert number to call. Jerry shared his paperwork with the local Medicare office.
Switching Health Plans
Martha S. recently changed jobs and had to change health plans. A week after her new health plan took effect, she had a practitioner’s visit for a follow-up of her high cholesterol. Along with her office visit, Martha also had some blood tests. She was surprised when she received an EOB indicating that the healthcare provider’s and the lab’s claims for her services were denied. Martha noticed that the EOB was not from her new health plan.
Martha called her healthcare provider’s office and found that the billing office had not updated her information and had billed her previous health plan. Once they sorted out the details, the medical office was able to resubmit the claim to Martha’s new insurer.
Look Over Every EOB and Medical Bill
First, make sure you receive an EOB after every visit to your practitioner or another healthcare provider. Every time a provider submits a claim on your behalf, your insurance company must send you an EOB. Call your health plan if you do not get an EOB within six to eight weeks of a health-related service.
(Original Medicare sends out Medicare Summary Notices every three months, for enrollees who had claims during that three-month period. Unlike EOBs from private insurers, MSNs are not sent after every claim.)
When You Get Your EOB
Check to make sure the dates and services you received are correct. If you find a mistake or you are not sure about a code, call your healthcare provider’s office and ask the billing clerk to explain things you don’t understand.
Watch out for possible billing fraud or medical identity theft. If you did not receive the services or equipment listed on the EOB, contact your health plan (outright fraud—as opposed to mistakes—is rare, but it does sometimes happen).
Read the remarks or code descriptions at the bottom or the back of your EOB. These remarks will explain why your health plan is not paying for a certain service or procedure or paying less. Some common remarks are:
If your claim is being denied due to any of these reasons, understand that you can submit an appeal if you don’t think the denial is justified. As long as your health plan isn’t grandfathered, the Affordable Care Act guarantees your right to an internal appeal, and if that is unsuccessful, an external appeal. That doesn’t mean you’ll win your appeal, but it does mean that the insurer has to consider your appeal and also allow for the external review.
(Note that even if your health plan is grandfathered, you do have a right to an external appeal if the claim denial is due to a situation in which theNo Surprises Actis applicable—ie, an out-of-network bill for emergency services or for services that were provided at an in-network facility.)
Summary
With most health plans, an Explanation of Benefits (EOB) is sent out to the patient and the medical provider after the health plan processes the claim. The EOB shows the amount that was billed, the amount that was written off due to the provider’s contract with the health plan, the amount that the health plan paid (if applicable) and the amount that the patient owes (if applicable). If the patient is responsible for paying some or all of the charges, the medical office will use the EOB to generate a bill that’s sent to the patient for their portion of the charges.
A Word From Verywell
There are several steps in the process of filling out and submitting a medical claim. Along the way, the humans and computers involved in the process can make mistakes. If your claim has been denied, don’t be shy about calling both your healthcare provider’s office and your health plan.
1 SourceVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Centers for Medicare and Medicaid Services.Guidance for States, Plans, and Issuers on State External Review Processes Regarding Requirements in the No Surprises Act. February 1, 2022.Additional ReadingCenters for Medicare & Medicaid Services.Internal Claims and Appeals and the External Review Process Overview. Published April 2018.Department of Health and Human Services.Reading Your Explanation of Benefits. Updated July 2018.
1 Source
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Centers for Medicare and Medicaid Services.Guidance for States, Plans, and Issuers on State External Review Processes Regarding Requirements in the No Surprises Act. February 1, 2022.Additional ReadingCenters for Medicare & Medicaid Services.Internal Claims and Appeals and the External Review Process Overview. Published April 2018.Department of Health and Human Services.Reading Your Explanation of Benefits. Updated July 2018.
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Centers for Medicare and Medicaid Services.Guidance for States, Plans, and Issuers on State External Review Processes Regarding Requirements in the No Surprises Act. February 1, 2022.
Centers for Medicare & Medicaid Services.Internal Claims and Appeals and the External Review Process Overview. Published April 2018.Department of Health and Human Services.Reading Your Explanation of Benefits. Updated July 2018.
Centers for Medicare & Medicaid Services.Internal Claims and Appeals and the External Review Process Overview. Published April 2018.
Department of Health and Human Services.Reading Your Explanation of Benefits. Updated July 2018.
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