Had to deal with an EOB lately?
Scary, wasn’t it? Worse than trying to decipher your cell phone bill, wasn’t it?
An EOB, an Explanation of Benefits, is a statement sent by a health insurance company to a covered individual that explains what medical services or treatments have been paid on his or her behalf. They are invariably marked somewhere ‘This is Not a Bill‘; the statements generally detail:
- Service or treatment performed, including the date or dates of the service or treatment; the description and/or insurer’s code for that service; the name of the patient; the name of the person or place that provided the service or treatment.
- The amount or fee charged by the doctor, and what the insurer pays towards that amount or fee. This is indicated by the dollar amount changed by the doctor or hospital, minus any amount applied against that charge by the insurer.
- The dollar amount you (or the patient) are responsible for.
- A brief explanation of any claims that were denied. The appeals process will also be explained.
Confusion and frustration is almost inevitable here, for a whole bunch of reasons. EOB forms and language are not standardized; format and terminology, style and content, shape and size – they all vary significantly from carrier to carrier. The same words most emphatically do not have the same meaning. Hospital visit EOB’s often look very different from doctor visit EOB’s, not to mention those issued for dental services and medications.
To make it even worse, there are always at least three parties involved: the ‘payer’
or health insurance carrier; the ‘provider’
or doctor or hospital; and the ‘patient’
– you or a family member.
What are insurers trying to accomplish, here? Good question.
Oddly enough, they are trying to clarify
The form’s basic purpose is not to confuse us, but to define and confirm exactly which medical treatment and/or service an insured received
. The ‘when’ and ‘where’ of this service is also specified. Next, the money part: the form conveys two things here – what the ‘provider’ charged for that treatment and what the ‘payer’ (the insurance company) has agreed to pay towards that treatment.
If a ‘payer’ (the insurance company) is denying all or part of a claim, they are required to indicate why they have made this decision, and to allow for an appeal.
Finally, the important part: how much the ‘patient’ owes.
Seriously! Could it be much worse? And just the other day we established that it is very important to review all these forms, not just for the money part, but to make sure the explanations of the services and treatments received are correct so that our medical records are up to date and accurate.
Could they have made it any harder?
Okay. Next we will organize a decent glossary of decoding terms so we can navigate this hazard!
Courage! We can do this!