Published: November, 2021
A medical crisis comes with several challenges. First is understanding the course of action and treatment plan recommended by your physician. Next is following the medication regimen. All of it can be pretty stressful. Finally comes the bill. From the medical jargon to high prices, it can be challenging to understand what you are responsible for paying.
This issue gets compounded by the number of errors that can occur on the average medical bill. But how can you ensure you are avoiding incorrect costs when you do not understand the jargon used throughout the documentation? Below are some tips and tricks to consider when reviewing your medical bill.
EOB or Medical Bill?
An EOB is a statement that you receive from your insurance company that lists your accepted treatments and medical services, and shows the total coverage based on your insurance policy.
A medical bill is a full breakdown of the medical services provided. This bill will show the date of service, total service amount, the amount your insurance company has covered and paid, and lastly, the amount, if any, that you are responsible for paying.
Let's focus first on insurance statements and their related terminology.
- Explanation of Benefits. An explanation of benefits is a statement sent by mail from the insurance company. Contrary to what some may think, this explanation of benefits is not a bill. Instead, the letter shows the submission process of the claim to the insurance company according to the patient's policy.
- Deductible. A deductible reflects the dollar amount you, the patient, are responsible for paying before insurance pays for medical services.
- Copay. A copay is a fixed fee put in place for the patient to pay for medical services. For example, one can expect to pay a copay for primary care physician appointments, lab testing, urgent care visits and emergency room visits. The copay will vary depending on both your insurance company and the policy.
- Out-of-Pocket Maximum. This amount reflects the maximum amount you will pay within a policy year before insurance will begin to pay 100 percent of your medical services.
- Ineligible Services. If you see "ineligible services" listed on your medical bill, this is simply stating that your insurance policy did not cover a specific medical visit, test or procedure.
Understanding Medical Billing Terminology
Medical bill terminology describes the amount a patient is responsible for versus the amount insurance has agreed to pay on their behalf. Insurance typically covers a portion of the costs, with the remainder required to be paid by the patient or sent to secondary insurance if one is available. But what does this medical billing terminology mean?
There are many components to know to understand a medical bill, so let's break them down.
- Date of service.This reflects the date on which you received the medical service or procedure.
- Member. In this space, you will see the patient's name, whether you or a member of your family listed on your insurance policy.
- Description. The description section summarizes the services provided, the procedure performed, and/or lab testing performed.
- CPT codes. Current procedural terminology, or CPT codes, reflect a five-digit number that directly corresponds to the service received. Medical billers use these to ensure proper billing for the performed procedures.
- Charge. This price represents the total amount of the service provided. You are not responsible for paying this amount.
- Adjustment. The discounted rate that your medical provider and insurance company approve and your insurance's current payments for your medical bill.
- Balance. This amount reflects the actual amount owed by you, the patient.
Correcting Your Bill
If you are one to diligently review a medical bill before sending the payment of the remaining balance owed, you are likely to spot an error or two throughout your review. While it can be frustrating to receive an incorrect bill, remaining calm throughout your discussion with all involved will likely help your case in the long run.
The first step to correct your bill is to request an itemized bill from your insurance company. This bill will reflect:
- Date and time of services provided
- CPT codes
- Total price
- Amount due by the patient
Once you have received this and reviewed it, you will contact your medical provider's billing department and request a representative regarding your bill. They will likely place you on a brief hold while they research the discrepancy or advise you of a specified time frame for the error to be fixed, typically 4-6 weeks.
If you cannot make progress with your medical provider's billing department, you may file an appeal with your insurance company. They will be more than happy to help you with the error as they do not want to pay more than they have to, either.
Next, you will file an appeal with your medical provider's patient advocate if you have not received the help needed.
As a last resort, if no one else has seemed to help correct the errors, you can contact your state insurance commissioner. You will be required to fill out an official complaint form and attach all documentation and paperwork to this form. At this point, you should consider contacting an attorney.
Medical bills can come with quite a headache. If you need to dispute an invoice, you must take diligent notes of any conversations regarding your account. Ideally, you would record the phone calls when you can do so. If you are sending anything by mail, ensure you keep a copy for your records as well.