EOB’s (Explanation of Benefits)

EOB’s are the reports you get from your insurance company.

Not all EOB’s are identical, but they may have all or some of the following information ~

                       

Patient Name:                              This is the patient that is receiving the services.

Insured’s Name:                          This is the person who carries the insurance policy under them. 

I.D. Number:                                 This is usually on the front of the insurance card and identifies the patient.

Group Number:                           This identifies which group health insurance the patient belongs to.

Patient Account Number:       This is an identifying number the provider-of-services assigns to the patient.  (Each provider has their own patient account number.)

Claim Number:                            This is a number that the insurance company assigns to each claim to identify it.

Dates-of-Service:                        The dates you were seen and had services.

Units-of-Service:                         Denotes the amount of something provided, such as charged hours or medication amounts.

Billed Amount:                             What your provider billed the insurance company.

Allowed amount:                        The amount your provider is contracted to bill the insurance company.

Contractual Adjustment Amount:  The contracted amount that has to be written off the charges.

Notes:                                              Denotes information pertinent to the claim/charges.

Deductible:                                    The dollar amount applied to your annual deductible on the claim.

Co-Pay Amount:                          The dollar amount applied to your annual coinsurance on the claim.

Amount Paid:                                The dollar amount the insurance company paid to your provider.

When calling your insurance company about a claim, always have the EOB available as you will likely be asked information directly from it.

QUESTIONS - QUESTIONS - QUESTIONS

My daughter suggested I open my blog up to a question and answer page.  I’ll look into trying to create a separate section just for this, but in the meantime, if you have any questions, what-so-ever, I’ll try to answer them to the best of my ability, or direct you to the proper resources that can help. You can add a comment to any question or comment to any posting or email me directly.  Did you know there is an entity that you can report suspected insurance fraud?  A group that helps with Medicare related problems?  Did you realize there are even laws that regulate and govern health insurance and those who are responsible for administering it?   There are no “wrong” questions to ask.  Now here’s my question…. who will be the first one to ask me a question?

REFUNDS, REFUNDS, REFUNDS

My youngest daughter recently went through some rather expensive claims, where we saw #1) Nurse Practitioner , then a few days later #2) Went to the emergency room, had ER charges (facility) and separate ER Physician charges (professional)  and lastly was referred to #3) ENT/Plastic Surgeon.  Our deductible is $500.00, than they pay 80% up to $1500.00, then100% thereafter.  Needless to say, she’s met her deductible and were well on our way to meeting her out-of-pocket.  Here’s where the refund comes in.  When we finally made it to round #3, the physician charged us a consultation and then did an office surgery on my daughter.  Our insurance has a $20.00 co-pays for office visits/consultations.  We paid that, as we realized it was due.  The next part of the bill was for her office surgery.  This was charged separately from the consultation and billed accordingly.  The charge for this part of the service was $345.00; insurance allowed $189.96, and the write off was $155.04 (patient savings for going to a preferred provider).  The $189.96 went towards our deductible, which we paid up front.  Nine days later we had to go back to the physician for a follow-up on her surgery.  Again we were charged a $20.00 co-pay which we paid up front.  Around two weeks later I received an explanation-of-benefits (EOB) from our insurance company stating that the follow up visit was included in the surgical fee.  Benefits are not payable for this as a separate expense.  Okay, so I figure I’ll be getting a check back for the $20.00 we paid up front.  First week goes by, nothing.  Second week goes by, nothing.  At this point I call the physician’s office and ask for the phone number to his billing office.  I’m tell them who I am and am told back that they do their own billing, the biller is on another line and will call me back.  This is usually code for, “take a message so I can see what’s going on with the claim.”  About thirty minutes later “Karen” called me back.  She said that “yes, we are due a refund, she will send the information to the bookkeeper and we will either get it this week or the following week.” Having worked in a billing office, I frequently used the line, “Your refund request has been sent to our bookkeeper and it will take about ten business days to get back to you.”  Truth-be-told, our “bookkeeper” was ten feet away from me in another room.  When you use the term “bookkeeper” it sounds like an accountant’s office in a whole other building. Do you think I would have automatically received our refund if I had not called the doctor’s office?  My guess is probably not.

Today’s lesson:  It’s important to scrutinize your EOB’s and make sure you follow-up on refunds that you feel are due to you.  If you don’t do this, who will?

Billing and Coding Confusion

Insurance billing/coding can be as confusing to understand as it is to actually do.  Every year new coding (CPT and ICD-9) books come out with changes and updates.  New codes may be added and some codes may be deleted altogether.  There are also numerous bulletins that providers get from insurance companies letting them know their changes to their own policies and procedures. Mistakes can easily happen when you’re dealing with hundreds or thousands of insurance companies with different guidelines and policies, therefore it is extremely important to keep on top of matters if your claims get denied.  Denied claims could be something as easy as your provider using an obsolete code to a making a typographical error.