**Unraveling The Mystery: Tracking Insurance Payments And Their Impact On Your Bills**

Understanding your medical bills can be confusing, but it's important to know what to expect financially when you need to go to the doctor. After you visit your doctor, their office submits a bill (also called a claim) to your insurance company. This bill lists the services provided to you and the costs. The insurance company then uses this information to pay your doctor for those services. When the insurance company pays your doctor, they might send you a report called an Explanation of Benefits (EOB). This will show you what the insurance company did when it received your doctor's bill. You need to be able to read and understand the EOB to know what your insurance company is paying for, what it's not paying for, and why. An EOB is not a bill.

Understanding your medical bill

Medical billing in the United States can be a confusing process. A 2016 survey found that around 72% of American consumers are confused by their medical bills. However, understanding your medical bill is important to ensure that you are not being overcharged for services. Here are some tips to help you understand your medical bill:

Ask for an itemized bill

You are entitled to an itemized bill, which breaks down each service or product you received along with the corresponding charge. You usually have to request this from your healthcare provider, as they often send a summary bill that only states the total amount you owe.

Understand the components of your bill

Your medical bill will include basic information such as the dates of service, a description of the services provided, and the charges for each service. It may also include medical codes such as CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) codes, which represent the services provided. These codes can be looked up online to ensure that you are being charged correctly.

Compare your bill with the Explanation of Benefits (EOB)

After your doctor's appointment, your doctor's office submits a claim to your insurance company, which includes a list of the services provided. The insurance company then sends an EOB to you, explaining what they paid for and why. Compare this with your medical bill to ensure that the services and charges match.

Look out for errors

Medical billing errors are common, so it is important to scrutinize your bill carefully. Check for things like misspelled names, incorrect dates, duplicate charges, or treatments you didn't receive. If you spot any errors, contact your healthcare provider's billing office to have them corrected.

Understand your insurance coverage

Know what your insurance plan covers and what your out-of-pocket expenses will be. Understand terms like copay (a fixed dollar amount you pay per visit), deductible (a fixed dollar amount you need to pay before your insurance starts covering costs), and coinsurance (where you pay a percentage of the total costs).

Keep records

Save all receipts, bills, and explanations of benefits, and record the dates and details of your healthcare visits. This will help you keep track of your expenses and identify any errors.

Contacting the insurance company

Contacting your insurance company is a good way to find out if they have paid a bill. Here are some steps you can take:

Firstly, you should find the contact details of your insurance company. This may be on your insurance card, or you can search for the company's website or customer service phone number online. Many insurance companies offer 24/7 customer support, so you can try reaching out to them at any time.

If you have an account with your insurance company, you may be able to log in and access information about your coverage and payments. You can also try creating an account if you don't have one already. This may allow you to view your payment history and see if a particular bill has been paid.

When contacting your insurance company, whether it be via phone, email, or online chat, it is important to have some key information ready. This includes personal details such as your name, date of birth, address, and policy number. You should also have details of the bill in question, including the date of service, the type of service received, and the amount charged.

Once you are in contact with a customer service representative, you can inquire about the status of the bill in question. You can ask if the insurance company has received the bill, if they have processed it, and if they have made a payment. If the bill has not been paid, you can ask about the expected timeline for payment.

It is also important to understand your insurance coverage and how it applies to the bill in question. Ask the customer service representative to explain how your coverage applies to the specific service or treatment you received. They can clarify what is covered by your insurance and what you may be responsible for paying out-of-pocket.

If you have any questions or concerns about your insurance coverage or the payment process, don't hesitate to ask. You can inquire about the reasons for any delays in payment or why certain items may not be covered. It is your right to understand how your insurance benefits are being applied.

Remember to take notes during your conversation with the insurance company. Make a record of the date and time of your call, the name or ID number of the representative you spoke with, and any important information they provide. These notes will be useful for future reference or if you need to follow up again.

By following these steps and contacting your insurance company, you should be able to effectively determine whether they have paid a particular bill and gain a better understanding of your insurance coverage.

Explanation of Benefits (EOB)

An Explanation of Benefits (EOB) is a document sent by an insurance company to the insured, which details the costs of healthcare services received. It is generated when a healthcare provider submits a claim for the services provided. An EOB is not a bill, but it does show the amount the patient is responsible for paying. It is important to keep your EOBs and compare them to your bill to ensure you are being charged the correct amount.

An EOB will usually include the following:

• Patient details
• The medical services received and from whom
• Amount billed—the cost of those services
• Discounts—any money saved by accessing care or medical products from within the insurance plan's network of providers
• Amount paid by the health insurance plan
• Amount not covered—costs the health plan did not cover
• Amount paid from spending accounts, such as a health reimbursement account (HRA), if applicable
• Any outstanding amount the patient is responsible for paying
• Glossary of terms and definitions, with instructions for how to appeal a claim, if necessary
• More specific details about the cost of the care received

The EOB is a useful tool for showing the value of a health insurance plan, as it outlines the costs of the services received and the savings the plan facilitated. It also helps the insured gauge how much money they have left in their accounts. For some plans, EOBs also show how close the insured is to meeting their annual deductible.

Deductibles and co-payments

A deductible is a fixed amount that a patient must pay each year before their health insurance benefits begin to cover the costs. Deductibles are an annual amount that must be paid for covered healthcare services before insurance begins paying. Deductibles are cumulative yearly amounts. For instance, if you have an annual deductible of $4,000, you may have to pay $4,000 out-of-pocket to meet your deductible before your insurance will pay for your care.

Co-payments, or co-pays, are typically charged after a deductible has been met. However, in some cases, co-pays are applied immediately. A co-payment is a fixed amount that a healthcare beneficiary pays for covered medical services. The remaining balance is then covered by the person's insurance company. Co-payments are usually a predictable fixed cost and are distinct from coinsurance, which is a percentage of the total cost that the individual is responsible for.

Co-pays are typically lower for standard doctor visits than for seeing specialists. Co-pays for emergency room visits tend to be the highest. Co-pays are usually a predetermined rate based on your health insurance plan and can be found on your ID card.

Co-pays and deductibles are both features of most insurance plans. The difference between co-pays and deductibles comes down to the type of services and goods covered, the payment structure, predictability, and when they apply. Deductibles typically apply to a broader range of services, especially major medical costs, while co-pays are often for specific services like doctor visits, prescriptions, or emergency room visits.

Your deductible is an amount you must pay out of pocket until your insurance will kick in and start paying. For instance, if you have a deductible of $2,000, you may have to pay the full cost of any particular health care service you receive – like going to a specialist doctor's appointment or getting labs done – out of pocket until you pay $2,000. After you reach your deductible, co-pays may still apply.

For example, you may have a co-pay of $15 when you go to visit your primary care provider. Your insurance may cover the rest of the cost if you've reached your deductible.

Other Out-of-Pocket Expenses

In addition to co-pays and deductibles, there are other out-of-pocket expenses that you may encounter. These include:

• Coinsurance: A percentage of costs you pay for a covered healthcare service after you've paid your deductible. For example, if the insurance covers 70%, you pay 30% coinsurance.
• Out-of-Pocket Maximum/Limit: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, co-payments, and coinsurance, the insurance company pays 100% of the costs of covered benefits.
• Non-covered Charges: Costs for services that your insurance plan doesn’t cover. Examples can include certain drugs, procedures, or alternative therapies.
• Excess Charges: Additional charges from a provider who doesn’t accept your insurance plan’s payment as full reimbursement. Common in plans without out-of-network benefits or in Medicare Part B.
• Prescription Drug Costs: Specific costs for medications, which can vary based on drug tiers and whether a drug is generic or brand-name.
• Premiums: The regular payment you make to have health insurance, typically monthly, independent of the services you use.
• Travel Costs for Medical Care: Expenses related to traveling for treatment, like transportation and lodging, which are often overlooked.
• Facility Fees: Additional charges from hospitals or clinics for using their facilities, separate from the cost of the medical procedure.

Coinsurance and out-of-pocket expenses

Coinsurance is a percentage of the cost of a covered service. This is your share of costs for healthcare services. Coinsurance usually kicks in once you've met your deductible. For example, if your coinsurance is 20%, you'll pay 20% of the total medical bill, and your health plan will pay the remaining 80%.

The out-of-pocket maximum is the most you'll have to pay per year for covered healthcare services. When you have spent this amount in your plan year on deductibles, copayments, and coinsurance for in-network care and services, your health insurer will pay for 100% of your healthcare services. This helps you to control the cost of your healthcare because you know the maximum you will ever have to pay in a year.

The out-of-pocket maximum for a Marketplace plan in the 2023 plan year cannot be above $9,100 for an individual and $17,400 for a family.

Frequently asked questions