Let's say you recently visited your doctor, and you're wondering how much that visit is going to cost. Then one day you get something in the mail or your email that sort of looks like a bill – it even says "amount you owe" at the bottom. But it's missing the usual tear-off portion and return envelope. Confused? You're not the only one.
Most likely it's an Explanation of Benefits (EOB) from your health insurance plan. We get a lot of questions about EOBs from our members. Here's a little primer on why you got that EOB and what you're supposed to do when you get it.
Should you pay your EOB?
The Explanation of Benefits is not a bill. So, no, you shouldn't pay anything yet. It's a report of what your insurance plan is going to cover, based on the care you received, and your health plan benefits for that care. If there’s an amount you owe noted on the EOB, you will receive a separate bill from your doctor for the portion that you need to pay.
How to read your EOB
The important things to check first are the services you received and the date you received them to be sure they’re accurate. Next look for the plan paid amount, which is how much your insurance plan covered and paid to your doctor. If your plan has a deductible, copay, or coinsurance (a set percentage you must pay), it all gets figured into the equation. What's left over is the amount “you owe,” which is listed in the Member Responsibility section of the EOB.
Understanding claim adjustments and EOB reason codes
Your insurance company uses EOB reason codes to explain why a claim has been denied. There are a variety of reasons a claim could be denied, like your insurance company needs more information to finish processing your claim, services were out of network, or a prior authorization is needed (to name a few).
If a service was denied, the reason code will explain why it wasn’t covered by your plan and may even provide recommendations for next steps you should take. If no adjustments were made to your claim, no reason codes will be listed.
Reason codes are generally vague to protect each patient’s privacy. If you need more detail to understand which visit or part of a visit the EOB is about, you should call Member Services at your insurance company to learn more.
What does an EOB look like?
An EOB statement’s formatting will vary by insurance company, but it usually includes:
- Personal details like your name, member number and plan information
- Information about your visit including the date(s) of service, your doctor or clinic’s name and the high-level type of the care you received (e.g., preventive care or office visit)
- A breakdown of the charges for service(s) received so you can see how much your insurance company paid and the amount you owe
HealthPartners members can look at this Explanation of Benefits example so you will know what to expect.
What to do if your EOB and bill don’t match
If your Explanation of Benefits and bill from your doctor’s office don’t match, there could be a few things going on:
- A prior balance could have been carried over for unpaid medical expenses at your doctor’s office or your bill might include charges for more than one date of service.
- A payment may have been made at the time of service or another point between when the EOB and bill were sent.
- A hospital or clinic may have sent you a bill before your insurance company had an opportunity to pay. If this happens, wait until your insurance company processes the claim, and then you may be reissued an updated bill.
If you notice a difference in the amount on your EOB and the bill you receive from your doctor’s office, you should call your doctor or clinic to see if your account has been updated with a payment from your insurance company or elsewhere since the bill was sent. If you still need help, you should then call Member Services at your insurance company for an explanation.
How long should you keep your EOB?
You should always save your Explanation of Benefits until you get the final bill from your doctor or health care provider. Insurance companies make it easy for members to view past EOBs online, so there’s no need to keep a paper copy if you have an online account.
Compare the amount you owe on the EOB to the amount on the bill. If they match, that's the amount you'll need to pay to your doctor’s office. Keep in mind that you will often get more than one EOB if you received more than one type of service or treatment at the same visit, or if you received treatment on more than one day. For example, if you are treated at a hospital, you will likely get at least two separate EOBs: one for hospital charges and another for the doctor’s time.
If you have several EOBs for the same visit, compare them to your bill. Your bill should itemize the services you received so you can confirm what was billed and what was covered for each part of the clinic visit or hospital stay, even if those are on multiple EOBs.
What if you don’t get an EOB?
If you are a member of a health plan and your doctor’s office has your insurance information, they generally submit the insurance claim for you. But if they don’t have that capability or you go to an out-of-network provider, you may have to submit the claim yourself. In that case, you may get a bill from your doctor or health care provider before you get an Explanation of Benefits.
There are also situations where you may not receive an EOB. For example, many HealthPartners plans don’t send an EOB if the member doesn’t need to pay anything.
Either way, don’t pay your clinic or hospital bill until you receive an EOB for that service. That way you can feel confident that you're not paying more than you owe.
Of course, if you have questions about a bill or an Explanation of Benefits, you can always call Member Services at your insurance company for answers. They are happy to talk you through your EOB and help you figure out what you owe.
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