Medical records contain the patient's history of illness and injuries, but they may contain more than that. The bills that are associated with the treatment that a patient receives also contain information about the patient. In addition to the standard information that the insurance company needs to pay the bill, there are also codes regarding the diagnosis of the patient as well as the services that were provided to the patient during that visit.

When the insurance company receives these codes, the codes then become part of the patient's medical history too. In an ideal situation, the actual diagnosis and treatment provided by the physician matches the codes that are submitted to the insurance company. Unfortunately, the patient's medical record and the bill sent to the insurance company sometimes do not agree. In most cases, this is a simple human error but needs to be corrected.

When the bill is submitted with the wrong code, the insurance company now has the wrong diagnosis or service associated with the patient's medical history. It would be very detrimental for "heart attack" to be entered in a patient's medical history instead of the true diagnosis of "chest pain". In addition, different codes represent different reimbursement amounts for the physician and different out-of-pocket expenses for the patient. The out-of-pocket expense to a patient for an "office visit code" would be considerably cheaper than a "surgery code".

The insurance company sends out an Explanation of Benefits (EOB) to the patient following each claim that is processed. This EOB tells the patient what services the provider billed for, how much the provider was paid, and how much the patient owes the provider. It is important for patients to review each EOB that they receive to insure the accuracy of this information. If there is an error, it is important to get it corrected immediately. The effects of this kind of error may not be realized for many years, but will be much more difficult to correct at that time. The key is to make sure that you know what your medical record says about you before it is too late to make the necessary corrections.