Jane Dotson
Understanding your medical insurance bill is an important part of staying on top of your finances. Medical billing can be complex, with multiple parties involved, and errors can occur. It is important to know how to read and interpret your bill, and to understand the costs of your care, what your insurance covers, and what you may need to pay yourself. This process can be made easier by familiarising yourself with the various terms and sections of your bill, such as service dates, descriptions, charges, adjustments, and payments. Comparing your bill with any notices or communications from your insurance company can also help you identify any discrepancies.
| Characteristics | Values |
|---|---|
| What to do before receiving a bill | Contact the consumer reporting agencies that specialize in medical records or payments to get a report on your prescription drug purchase histories, medical conditions, data from your insurance applications, etc. |
| What to do after receiving a bill | Compare the bill with the Explanation of Benefits (EOB) to make sure you were billed for the correct services and supplies. |
| What to do if there is a discrepancy | Contact your provider or facility. If the bill is $400 or more above the amount of the good faith estimate, you may be able to dispute the bill. |
| What to do if you don't have insurance | You will usually need to pay the full amount shown on the bill. Your provider or facility must give you a "good faith estimate" of expected charges before you get an item or service if you ask for one. |
| What to do if you have insurance but don't plan to use it | You will usually need to pay the full amount shown on the bill. Your provider or facility must give you a "good faith estimate" of expected charges before you get an item or service if you ask for one. |
| What to do if you have questions about your bill | Contact your provider or facility. You can also contact the No Surprises Help Desk for help in over 350 languages. |
| What to do if you have questions about why your insurance company did not cover something or about the amount you have to pay | Contact your insurance company. |
| What to do if your insurance company hasn't paid your doctor | Contact your insurance company if more than 60 days have passed. |
| What to do if you are unsure if your coverage has started | Check your online Marketplace account or call your insurance company. |
| What to do if you are unsure how to pay | Reach out to your insurance company if you don't get details on how to pay. |
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What You'll Learn
- Understanding the bill's breakdown: dates, services, charges, adjustments, and payments
- Comparing the bill to the Explanation of Benefits (EOB) to check for errors
- Knowing what to do if there is a discrepancy between the bill and EOB
- Reviewing your medical history and payment records for accuracy
- Contacting the insurance company and healthcare provider with any queries or disputes
Understanding the bill's breakdown: dates, services, charges, adjustments, and payments
Understanding the breakdown of a medical bill can be challenging due to the complex terminology and coding used. However, it is essential to review your bill to identify any discrepancies or errors. Here is a detailed breakdown of the components you may find on your medical insurance bill:
Dates:
The "Service Date" or "Date of Service" column on your bill lists the dates you received each medical service. It is crucial to verify that the dates on the bill match the dates you received treatment. If you were admitted to the hospital after midnight, ensure that the charges start from that day, and if discharged in the morning, confirm that you are not charged for the full daily room rate.
Services:
The "Description" or "Procedure Description" section provides a short phrase or code explaining the services, supplies, or procedures you received. These descriptions can sometimes be vague, contain abbreviations, or include complex medical terms. If you are unsure about a listed service, contact your healthcare provider or facility for clarification.
Charges:
"Charges" or "Total Charges" refer to the full price of the services, procedures, or supplies you received before insurance is applied. This amount is typically the same for insured and uninsured patients. If you have insurance, the "Billed Charges" represent the total amount charged to either you or your insurance provider.
Adjustments:
Adjustments are amounts that your healthcare provider has agreed to subtract from the total charges. This could be due to discounts or negotiated rates. Adjustments can also be based on the deductible and copay features of your insurance plan. The "Allowed Amount" is the maximum amount your insurance plan will pay for a covered service, and if your provider is out-of-network and charges more than this allowed amount, you may be responsible for the difference, known as "balance billing."
Payments:
"Insurance Payments" or "Insurance Payment Received" indicates the amount your insurance provider has already paid or is expected to pay. "Patient Payments" or "Patient Responsibility" refers to the amount you, as the patient, are responsible for paying. This may be influenced by deductibles, coinsurance, or copayments associated with your insurance plan. The "Balance" or "Amount Due" is the outstanding amount you currently owe the healthcare provider.
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Comparing the bill to the Explanation of Benefits (EOB) to check for errors
An Explanation of Benefits (EOB) is a notice you receive from your health plan that details the costs of your care. It includes the services you received and the dates you received them, the amount your health plan agrees to pay, and the amount you owe. It is not a bill, but it is an important tool that shows you how your bill is broken down between the medical service provider(s), your insurance, and you.
When you receive your medical bill, you should compare it with the EOB to make sure you were billed for the correct services and supplies. Check that the dates of service and description of services on your EOB and billing statement are the same and that they match other records you may have of the visit. If there are discrepancies, contact your doctor's office first.
The EOB will also show you any adjustments made to the total charges, such as discounts or lower rates agreed upon by the provider. It will detail the amount your insurance company has paid or is expected to pay. If you have questions about why your insurance company did not cover something or about the amount you have to pay, contact your insurance company.
Additionally, the EOB will outline any deductibles, copays, and coinsurance. A deductible is the amount you pay for healthcare services before your insurance starts to pay anything. A copay is a fixed amount you pay for a healthcare service covered by your insurance, typically due before the service is provided. Coinsurance is the amount you may be required to pay towards the claim, in addition to any copayments or deductibles.
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Knowing what to do if there is a discrepancy between the bill and EOB
If there is a discrepancy between the bill and the EOB, there are a few steps you can take to resolve the issue. Firstly, carefully review both documents and identify the specific areas of discrepancy, such as dates of service, descriptions of services, or amounts charged.
Next, contact your doctor's office or clinic to discuss the discrepancy. They may have updated billing information or insurance payments that have not been reflected in the EOB or bill. Ask them to explain the charges and provide clarification on any codes or abbreviations used in the billing. If there is a prior unpaid balance or multiple dates of service involved, this could also contribute to the discrepancy.
If you still have concerns about the bill or have questions about why your insurance company did not cover certain expenses, contact your insurance company directly. They can provide information on what your plan covers, the amount they have paid to the provider, and any remaining amounts that you are responsible for paying.
In some cases, you may need to dispute the bill. If the amount you are billed is significantly higher than the good faith estimate or if you identify billing mistakes, you have the right to question and dispute the charges. You can seek assistance from consumer reporting agencies or insurance help desks to understand your rights and resolve the issue.
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Reviewing your medical history and payment records for accuracy
It is important to review your medical history and payment records for accuracy. This is because you may have forgotten to inform your healthcare provider of something, or they may have forgotten to write down the information. Likewise, your provider may have misunderstood, incorrectly noted, or omitted something, such as details about your health history or symptoms. They may also have charged you for a test you did not take. If you do not check your records, you will not know if these mistakes have been made, and they could impact your future health and treatment.
You have the right to inspect, review, and receive a copy of your medical and billing records under the Privacy Rule. Only you or your personal representative has the right to access your records. A healthcare provider or health plan may send copies of your records to another provider or health plan only as needed for treatment or payment, or with your permission. A provider may charge for the reasonable costs of copying and mailing the records.
To review your medical history, you can request a copy of your medical records from your healthcare provider. You can also contact consumer reporting agencies that specialize in medical records and payments. These agencies can provide reports on your prescription drug purchase histories, medical conditions, data from your insurance applications, and other sources. Examples of such agencies include Experian, Equifax, and TransUnion, and you can request free copies of your reports from them every 12 months.
To review your payment records, you can refer to your Explanation of Benefits (EOB) and billing statements. The EOB shows the costs of your care, including the services you received and the dates you received them, the amount your health plan agrees to pay, and any amount you owe. You should receive an EOB from your health plan before you get a bill from your provider. If you do not, contact your health plan to ensure your provider has sent them a claim for your service. When you get a bill, compare it with the EOB to ensure you were billed for the correct services and supplies, and that the amounts match. If you do not have health insurance, you will usually need to pay the full amount on the bill.
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Contacting the insurance company and healthcare provider with any queries or disputes
When reviewing your medical bill, you may encounter queries or disputes that require you to contact your insurance company and healthcare provider. Here are some scenarios that may necessitate such communication:
Understanding Billing Terms and Codes
Medical bills often contain complex terms, abbreviations, or billing codes that can be challenging to interpret. If you come across descriptions of services or supplies that you don't understand, reach out to your healthcare provider for clarification. They can explain the specific services or items you received and how they are coded or described on the bill.
Discrepancies and Errors
It is important to compare your medical bill with the Explanation of Benefits (EOB) provided by your insurance company. The EOB details the costs of your care, including the services received, dates, and amounts covered by your insurance. If you notice discrepancies between the bill and the EOB, such as incorrect dates of service or inconsistent descriptions, contact both your healthcare provider and insurance company to resolve the issue.
Additionally, be cautious of potential billing errors or fraudulent practices. For instance, if you identify duplicate charges, significant differences between estimated and actual charges, or suspect upcoding (inflating charges by misrepresenting the diagnosis), engage with your healthcare provider and insurer to dispute these errors and seek corrections.
Payment-Related Queries
If you have questions about the amount you owe or why certain services were not covered by your insurance, don't hesitate to contact your insurance company. They can provide clarity on your coverage, deductibles, copayments, and coinsurance. If your insurance company has not paid your healthcare provider within the expected timeframe, reach out to them to understand the delay.
Moreover, if you are unsure about how to make payments or have concerns about payment methods, refer to your insurance company's instructions. Contact them if you need further clarification or if you encounter issues with online payment options.
Insurance Coverage and Claims
If you have specific queries or disputes related to your insurance coverage or claims, engage with your insurance company. For instance, if you believe you should have received an EOB but didn't, contact them to ensure your healthcare provider has submitted the necessary claims. Additionally, if there are concerns about the accuracy of your medical records or payment history, you can contact consumer reporting agencies specializing in medical records to obtain your reports and request corrections if errors are identified.
In summary, actively communicate with both your insurance company and healthcare provider to address any queries or disputes related to your medical bill. Stay vigilant in reviewing charges, comparing them with expected costs, and understanding your insurance coverage to ensure accurate and fair billing practices.
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Frequently asked questions
EOB stands for Explanation of Benefits. It is a document sent to insured individuals after a claim has been submitted by a healthcare provider. It explains what medical treatments and services the patient’s health insurance company agreed to pay for and what treatments/services the patient is responsible for paying.
Your medical bill will include the date you received each medical service, a description of the service or supply, and the charges. The charges will include the total amount charged, the amount the insurance company will pay, and the amount you are responsible for paying.
If you find an error on your medical bill, you should contact your insurance company and/or healthcare provider to dispute the error. You may also be able to submit a complaint online.
You should contact consumer reporting agencies that specialize in medical records or payments. These agencies may supply reports on your prescription drug purchase histories, medical conditions, data from your insurance applications, and more.
If you don't receive an EOB, contact your health insurance company to make sure your provider's office has sent them a claim for your service.
