 Tips
for Patients
Bills and Explanation of Benefits (EOB)
Understanding an EOB
Understanding your coverage and your co-pays
What to do when you receive unexpected
bills
When you have multiple health insurance
plans
How to process a claim with your secondary
insurance company
If you're like most people, you probably don't
want to deal with medical claims and insurance companies. But
if you don't deal with them, you're opening the door to problems
later on.
Based on our experience processing medical insurance claims,
the most important piece of advice we can give you is this:
Do not procrastinate on managing your
medical bills and
insurance claims. If you don't take care of them promptly,
you're asking for trouble. When you get a bill from your
doctor or a notice from your insurance company, open
the letter and read it. If you don’t understand it,
call and
ask questions. Be proactive!
Bills
and Explanation of Benefits (EOB)
An Explanation of Benefits (EOB) is a statement from your
insurance company determining how they have paid your claim.
Since there is neither a standard doctor’s office billing
statement nor a standard insurance EOB, it can take time and
patience to understand what they're telling you.
· Usually the first bill you receive from your doctor's
office after your visit lists all the procedures and the charge
for each one. However, if the bill is printed more than 30 days
after your visit, it's no longer itemized in this way and it's
difficult to know what it refers to. If you are not sure what
the bill is for, call the doctor’s office and ask. They'll
be happy to help you.
· An EOB from the insurance company can be even more
confusing. Most people need to read it a few times to understand
it clearly. Sometimes it requires a careful analysis to find
out exactly what they are telling you (see “Understanding
an EOB”). Often the insurance company does not explain
how they calculated their figures: this may make it difficult
for you to see what you owe.
Understanding
an EOB
When you receive an EOB, we recommend approaching it in this
way:
1. Look for the facility or provider’s name. Sometimes
it may be a name you don’t recognize. The date of service
will help you recall what appointment you had and whom you saw.
2. Find the date of service.
3. Look for the total charges.
4. Subtract the amount the insurance paid. Sometimes the insurance
pays you; sometimes the insurance pays the doctor. If there
is no check attached, that means they paid the doctor. If there
is a check attached, that means they are paying you and you
have to pay the doctor.
5. Subtract the patient responsibility. This is indicated on
the EOB in the columns for co-payment, co-insurance, and deductible.
6. The remaining figure is the amount the doctor must write
off. You should not be billed for this amount.
7. Write your check to the doctor for the patient responsibility
amount less the co-pay you were obligated to pay at the time
of service. If an insurance check was attached to the EOB, add
the amount of that check to your payment. Write the date of
service in the memo section with your account number from the
doctor’s office. If you handle this promptly, neither
the doctor nor his staff will have to follow up with you. They'll
have more time for patient care rather than paperwork, you'll
receive fewer bills and it'll be more convenient for everyone.
Understanding
your coverage and your co-pays
- Read your plan coverage booklet when your body and mind
are healthy. Don’t wait until you’re sick to understand
your coverage: it only adds to your stress. This may sound
obvious, but you'd be surprised how many people don't know
how much they have to pay or what they have to pay for. You
may need to read some sections more than once. If you have
questions, call your benefits manager or your insurance broker.
When your coverage is clear to you, you'll feel more confident,
and you'll reduce the possibility of misunderstandings later.
- Know how much your deductible is and the services to which
it applies.
- Know what circumstances require a co-pay. Plans vary--some
plans require a co-pay only at the doctor’s office and
not for lab visits, so it's important to be familiar with
the conditions of your particular plan.
- Pay your co-pays at the time of service. When you enrolled
in your plan, you became contractually obligated to do so.
This will reduce the number of bills you receive.
- Know whether your plan requires you to pay co-insurance.
Co-insurance means that the insurer and the insured share
part of the costs incurred. Under some plans, co-insurance
occurs after the co-payment and deductible are met. It is
usually based on a percentage, for example 60/40. This means
that after the insurance company calculates the allowed amount
of the claim, they pay 60% and the patient is responsible
for 40%. The percentages and formulas vary depending on the
insurance plan coverage.
- Pay with a check or credit card so you have a record of
your payment. Do this even if your co-pay is only $10.
What to do when you receive unexpected
bills
When you receive a bill you weren't expecting, it usually involves
one of two situations.
Situation 1
(You received an unexpected bill)
You have insurance; you received a bill from your doctor; it’s
been more than 30 days since your appointment; your insurance
company has not paid.
In this case there's most likely a problem with your claim
(i.e. someone in the claims processing chain is missing necessary
information). Here's how to resolve it.
1. Call your insurance company and ask if they have received
the claim from the doctor.
2. If not, ask the insurance company for their "provider"
mailing address and “provider” phone number. The
provider is the facility where you received services.
3. Call your doctor's office and provide the billing coordinator
with the following information.
a. Confirm they have the correct insurance listed on your account
(Note: They may ask you to provide a copy of your insurance
card).
b. Confirm the subscriber identification number and group/plan
number.
c. Give the billing coordinator the “provider” address
and phone number and ask them to resubmit your claim.
Situation 2
(You thought your claim was being processed automatically)
You have insurance; you received a bill from your doctor; it’s
been more than 30 days since your appointment; your insurance
has paid but the doctor is still billing you.
- This means the doctor’s office believes you owe them
money.
- When you send your payment to the doctor’s office
for your portion of the bill, please enclose a copy of the
insurance information (the EOB form that you received from
your insurance company) with your payment. The EOB states
what portion you owe (see “Understanding
an EOB”) and including a copy allows the doctor’s
office to make sure they applied the insurance company’s
payment and write-offs correctly.
Handling your medical bill in this manner enables the
doctor’s office to resolve your billing issue for
that date of service with minimal action on your part.
When you have
multiple health insurance plans
Do not assume that your doctor will
bill
your secondary insurance company!
Most doctors' offices don’t bill your second and third
insurance companies. You are responsible for any balance due
after your primary insurance pays its portion. Your doctor's
office will expect you to pay this balance.
However, sometimes both insurance companies pay claims without
any action on your part. When this happens, it means that:
1. You gave your doctors' office copies of insurance cards
for both your primary and secondary insurance
and
2. Your secondary insurance has arranged electronic crossover
with your primary insurance plan. This means that once your
primary insurance has paid your claim, it is then forwarded
electronically to your secondary insurance so that they can
process their share of the claim. If this happens, you're very
fortunate.
IMPORTANT
Giving your doctor both insurance cards does not mean that
both claims will be processed automatically for you. If
your secondary insurance does not have electronic crossover,
they cannot make automatic payments.
You can call your secondary insurance and ask them to set
up electronic crossover with your primary insurance company.
If this is available to them, they will do it. If it's not
available, you are responsible for obtaining payment from
your secondary insurance company yourself. For details on
how to handle this, please see “How
to process a claim with your secondary insurance company.”
How to process
a claim with your secondary insurance company
If you want your secondary insurance company to pay part of
your claim, submit the “Day Sheet” or “Super
Bill” you were given at the time of service along with
the primary insurance company’s Explanation of Benefits
form.
NOTE
If you have secondary insurance, your doctor's office will
give you a Day Sheet or Super Bill, stating what services
you received during your visit and the charges for each service.
Even if you have insurance coverage, you still have to actively
participate in resolving your claims. In fact, the more active
you are the more quickly your claims will be resolved, and
the less paperwork and headaches you will have. The more you
can assist your doctor's billing staff, the easier it will
be for them to help you resolve your bill. Due to privacy
laws, you can often obtain information faster than the doctor’s
office. When you are actively involved, the process becomes
easier and quicker for everyone.
If you help facilitate the resolution
of your claims,
you’ll avoid having your bills sent to collections.
These guidelines will make it easier for you to deal with
your insurance claims. You'll also ensure that your doctor
can devote more time to patients like you, instead of dealing
with bills and paperwork.
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