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Explanation of Benefits - Know What's Being Billed to your Insurance Plan

Updated on February 16, 2014

Understanding your Explanation of Benefits

Each time you visit a health care provider that bills for services you will receive an EOB or explanation of benefits from your health insurance provider. This EOB clearly states that it is not a bill, but merely an explanation of what treatment you recently received and what your provider of services billed for. It gives you codes and dollar amounts. I work in healthcare administration (in a limited capacity) and I often come across patients who either present with the EOB in hand or they make a frantic phone call regarding their EOB. It's always the same. The patient thinks they're being billed. Generally, EOB's will indicate to the member that they are responsible for the amount shown as the balance due. Who wouldn't have a heart attack? But, that's not the case. It's not a bill. The claim(s) shown on the EOB are still being processed and need time for completion. Give it a few weeks before giving yourself a heart attack.

However, you do need to review the EOB thoroughly to ensure that you are being billed fair and reasonable fees by your health care provider. Let's say for example that you go to the doctor's office and spend two minutes with the actual physician. Keeping in mind that his/her medical assistant not the physician completed most of your medical history. Now, your phsycian comes into the exam room. After seeing the physician, you feel that the visit was just "ok". But, lo and behold you receive your EOB and your doctor has billed your insurance company $400.00 for the visit. Is this fair and reasonable for a two minute visit? You didn't plan on paying to visit with a medical assistant, did you? So, why is your insurance company being billed so much? It's bitter sweet, but there is something you can do about it. Question it!! Report it!! Follow through with it!! Remember, the more a health care provider bills to your insurance company, the higher your out of pocket expenses become.

Doctors don't want the Board of Medical Examiners breathing down their necks. Most times they will adjust the bill. But, if you don't quesiton it...nothing will get done. If they don't adjust it and you don't report it...nothing will get done. And, if you sit back and wait and you don't follow through with it...nothing will get done. YOU will end of over paying.

Electronic Health Records

Most doctors use outside billing companies who submit their charges to insurance companies on their behalf. These billing companies use professional coders. On ocassion, they do question out of the ordinary coding, but at the same time they just bill what the physician has charged the patient because they go by what is documented and ultimately that is what they're being paid to do. So, if it's documented they bill it as is. But, has the age of electronic health records made it very easy for doctors to overcharge. Perhaps.

Electronic health records basically means that your doctor will use a computer software program designed for use in the medical field to type his/her notes regarding their visit with you. The issue is that these software programs are simply templates. They have categories within them and only require a mouse click here and there for easy accessing. The user (most likely the phsycians medical assistant) would simply highlight a category and free text information about the patient in some areas, while in other areas he/she would check off boxes which will prompt the software program by default to fill in the required information. Easy peasy, right? But, the purpose of EHR or electronic health records was to make physicians more responsible with the treatment of their patients. No more sloppy notes. No more prescription errors. With EHR, physicians are able to quickly review the patient's medical history, address medication and allergy alerts and send prescriptions electronically to pharmacies. They can also send the visit notes electronically to other physicians who may play a role in your heath care. It's that simple. And, while it's the doctor's medical assistant that is most likely inputting most of the information into your EHR, your doctor is still responsible for reviewing the information thoroughly. But, are they reviewing it at all? When your doctor walks into the exam room does he/she ask "what can I do for you today?" Well, that's when you should ask "did you read my chart?"

You need to make your doctor read it!! For example, when your doctor prescribes new medications, ask if your new medication will interact with the one's you're already taking. The EHR software will generate any interactions automatically. If you're seeing a specialist, make sure you request that your visit notes be sent to your primary care physician. This will ensure communication between both doctors. Ask for a copy of your visit notes if you wish. Your medical chart belongs to you. There should be no reason for denying your request.

You need to get the most out of your visit with your doctor. Remember, you are paying him/her for a service. And, they're not inexpensive. It's not your problem if your doctor's office overbooked appointments and he/she seems to be rushing you out. Take a list of questions with you and keep your doctor in the exam room as long as you need him/her.

Billing for Services

Current Procedural Terminology codes or CPT codes are used in the US to specifically identify what a health care provider is billing for. It is how your insurance company knows what to pay him/her. But, each CPT code comes with a description that indicates to the health care provider when he/she can use certain codes for certain type visits or services. This is the tricky part. Over coding can be easy for some physicians because the template used for your visit can be chock full of notes. Remember, earlier I mentioned that the template only requires check marks here and there to automatically fill in information. The medical assistant asks you most of the questions when he/she brings you into the exam room and your doctor simply signs off on the visit note. Well, this pretty little template is going to send your doctor's kids to the best colleges in the country if you don't play a proactive role in your healthcare.

Think about this for a minute. If your doctor spent two or three minutes in the exam room with you, then how is it possible that he/she can bill at the highest level and get paid? Well, your insurance company doesn't know better,that's how. They have no way of knowing that the actual face to face time with your physician was less than he/she billed for. It is extremely tough for insurance companies to thoroughly review the thousands and thousands of codes being submitted by health care providers daily. However, auditing healthcare providers is becoming a thing of the future. Insurance companies are taking a harder look at repeat coding by health care providers and questioning their findings. But, patient involvement can simplify this process. If insurance companies get enough complaints about a specific physcian and their poor practices, then they will investigate it.

If you suspect that your doctor has overcharged your insurance company for services, you should question it immediately. It could be a simple error, but most likely not. If you review your EOB and see anything suspicious report immediately. You can begin by calling your physicians office for clarification or correction. If that doesn't help then contact your insurance provider. Believe me, you don't want to overpay for services. Most people just pay and never look twice at their EOB, but it's what doctors are probably hoping for. Take a stand and question your medical charges the same as anything else you're paying for. Medicine is BIG business for some. But, don't let your health care provider forget why they took their oath.


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