How to Catch Medical Billing Errors

Welcome to our guide on understanding medical bills using the Explanation of Benefits (EOB) and the Summary of Benefits and Coverage (SBC). Don't worry if it sounds complicated – by the end of this video, you'll be able to use these important documents with confidence. Let's get started! 

 

You probably know that medical bills and insurance can be confusing. Did you know that it has been reported that up to 80% of medical bills contain mistakes? That means you might be paying more than you should or for things that you shouldn’t.

 

Our goal is to help you understand the paperwork related to your medical care so that you spend less time being confused and have the tools and confidence to speak up for yourself.

 

Before we dive into the details, let's talk about why it's important to understand your medical bills. It helps you know what services you received, what your insurance covers, and any extra costs you might have to pay.

 

To get started, you’ll want to gather up your medical bills, EOB, and Summary of Benefits and Coverage.

 

Understanding the Explanation of Benefits (EOB)

Let's begin with the Explanation of Benefits, or EOB. This is a statement you’ll receive from your insurance company or find under your account on your insurance company’s website. Even though it says it is ‘Not a Bill,’ it is still important.

 

The EOB tells you about the services you received, how much they cost, what your insurance covers, and if you owe any money.

 

Here's how it works. Your insurance company looks at your plan and tells you and your health care provider how they are handling your claim. The EOB shows what your provider is billing for the care that you received, how much the provider is allowed to charge based on the rate that the provider agreed to accept from the insurance company, the write off (the difference between the amount charged and the amount allowed for your care) and how much you are required to pay. Of the amount that the provider is allowed to collect, the EOB explains how much you owe. You may be responsible for all, or part, of the allowable, or you may simply owe a copay or coinsurance for the services you received. The EOB will show how much of what you owe counts towards your deductible and out-of-pocket maximum. The EOB will also explain how much, if any, the insurance company is paying your provider.  

 

Reviewing Personal Information

The first step is to check your personal information on the EOB. Make sure your name and the insurance plan are correct, especially at the beginning of the year, if you have made changes in coverage. Make sure that the provider listed for that claim is the one you saw on the associated date of service.

 

Decoding EOB Codes

EOBs might have what are called CPT codes. These codes tell the insurance company what services you received. If the EOB does not explain in lay language what the CPT code represents, you can do an internet search to find out.

 

Cross-Checking Charges

Now, compare the charges on your medical bill with the EOB. Check the dates, services, and costs. Did you receive all of the services listed? Were you told the cost would be one thing, but the bill or the EOB says something different? Are you being charged for something you shouldn’t be, such as a preventive care service? Examples of preventive care services include well woman exams, screening mammograms, or screening colonoscopies.

 

Understanding Summary of Benefits and Coverage

Next, let's talk about the Summary of Benefits and Coverage (SBC). This document gives you a quick look at your insurance benefits–what types of services your plan covers, the rules that determine what you will pay for the care you receive, and other important details. You’ll want to pay careful attention to the deductible, co-pay, and co-insurance costs, as well as what types of services are covered by the plan. By law, your insurance company must give you this information. Note that even if you are responsible for part or all of your premium costs, the SBC does NOT show these numbers. Also, the SBC is merely a snapshot of your benefits. For more comprehensive information, you’ll want to review, or at least have a copy of what is known as the Certificate of Insurance or Evidence of Coverage, aka EOC, which has far more details. If there is a discrepancy between the SBC and the EOC, the EOC info is what counts.

 

SBCs are typically several pages long and provide an overview of the general types of services covered under your plan, how they are paid for, and by whom.

 

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Calculating Your Responsibility

Based on the allowable amount, with the information found on your SBC you can determine what your costs should be for a given service. Make sure it matches what your EOB and plan say.

 

You should compare what you experienced during your medical visit with the bill and EOB. Make sure you were charged correctly and were not charged for a service or procedure you did not receive. If you're not sure, ask questions.

 

Addressing Discrepancies

If you find mistakes or have questions, call your insurance company. They have people who can address problems you find while looking at your bills and EOB. If there is a billing error, you should also contact your provider.

 

Tips for Efficient Reconciliation

Here are some quick tips: keep your insurance documents organized and in a place where you can easily get to them, don't hesitate to ask for help from your insurance company’s customer service department, and document any conversations with your insurance company or provider’s office. This note should include the date of the call, who you talked to, the purpose of the call, what explanation you were given, if any, the plan and when to expect next steps.

 

And that's it! Understanding how to compare your medical bills with the Explanation of Benefits and the Summary of Benefits and Coverage might seem tricky, but it can be done! Take the time to look at your EOB, compare it to your bill, and make sure everything matches up with your plan and your experience with the medical care you received.

 

Your health is important, and understanding your medical bills and insurance coverage gives you the power to take care of yourself – medically and financially.