Let’s say that you vis­it­ed the doc­tor and you are won­der­ing how much that vis­it is going to cost.  A short while lat­er, you receive some­thing in the mail that looks like a bill – and even says “amount you owe” at the bot­tom.  How­ev­er, it doesn’t have a return enve­lope or tear-off por­tion for the bill.  Con­fused?  You’re not the only one!

Most like­ly, you’ve just received an Expla­na­tion of Ben­e­fits (EOB) from your insur­ance com­pa­ny.  The most impor­tant thing for you to remem­ber is that an EOB is NOT a bill.  It is essen­tial­ly “one big receipt” that explains your vis­it.  It shows what was billed, how much you can expect your health plan to pay, and what you — the patient — have to pay. It is always impor­tant to review your EOB to make sure it is correct.

An EOB is a tool that shows you the val­ue of your health plan.  It will detail the cost of the ser­vices you received and how much your insur­ance will pay.

How do EOB’s work?

The health care provider will bill your insur­ance com­pa­ny after your doc­tor vis­it.  Then, your insur­ance com­pa­ny will send your EOB.  Lat­er, you will receive a bill for the amount you owe.  How­ev­er, if the bill does arrive before the EOB, don’t pay it yet.  Wait until you have the EOB in hand so you can com­pare it to your med­ical bill.

While an EOB will dif­fer from one insur­ance com­pa­ny to anoth­er, they typ­i­cal­ly all include the fol­low­ing information:

  • The Account Sum­ma­ry – lists your account infor­ma­tion with details like the patient’s name, date(s), and claim number.
  • The Claim Details – lists the ser­vices pro­vid­ed and the dates of the services.
  • The Amounts Billed – details the cost of the ser­vices and what costs your health plan did not cov­er. It will also include any out­stand­ing amount you are respon­si­ble for pay­ing.  If there is a por­tion that is not cov­ered by insur­ance, the rea­son why will also be listed.

Remem­ber, insur­ance com­pa­nies rarely pay 100% of the bill.  You will need to pay any applic­a­ble deductible, copay and coinsurance.

Deductible: The amount you pay for health care ser­vices before your insur­ance begins to pay anything.

Copay: A flat fee that you pay on the spot each time you go to your doc­tor or fill a prescription.

Coin­sur­ance: The por­tion of the med­ical cost you pay after your deductible has been met.  Coin­sur­ance is a way of say­ing that you and your insur­ance car­ri­er each pay a share of eli­gi­ble costs that add up to 100%.

Why is Your EOB important?

Med­ical billing com­pa­nies some­times make billing errors.  Your EOB is a win­dow into your med­ical billing his­to­ry.  Review it care­ful­ly to make sure that you did receive the ser­vice being billed and that your pro­ce­dure and diag­no­sis are list­ed and cod­ed correctly.

EOBs can help you under­stand how the health insur­ance sys­tem works and pro­vide trans­paren­cy in the com­pli­cat­ed finances of health care.  While the EOB may be com­pli­cat­ed, under­stand­ing it can help ensure that you and your fam­i­ly get the most out of your health insur­ance.  Know­ing what an EOB is and what is includ­ed on the state­ment ensures that you stay in con­trol of your health care finances.