Tips To Understanding Your Explanation of Benefits Statements

The Affordable Care Act (Obamacare) has now been in effect for over a year. Like millions of Americans, you may have enrolled for health insurance in the Health Insurance Marketplace possibly receiving health benefits for the first time.

If at any time you received medical care, chances are you will receive Explanation of Benefits (EOBs) statements from your health insurance company that you may be unfamiliar with. These EOBs are the result of claims submitted by the doctor or facility for health services you received and then processed by the insurance company based on your plan benefits.

The EOB you received from your insurance company is not a bill, but rather a detailed statement that explains what is covered and paid under your insurance policy. Below are some terms found on the EOB that you should pay attention to:

Provider Name – Indicates the name of the doctor or facility you received services from.

Date of Service – Indicates the date you received services from the doctor or facility.

Amount Billed – The amount your doctor or facility charged for services your received.

Approved Amount – Amount determined by a usual and customary fee schedule. This amount may also be determined by your geographic location.

Deductible – The amount that must be met before benefits are paid. There may be a higher deductible for doctors that are not participating in the network (out of network). Refer to your policy schedule of benefits as to what the amounts are.

Amount Paid – This is the percentage of the allowed amount paid to the doctor or facility for services rendered after the deductible has been met. The percentage paid may be lower for doctors or facilities out of the network. Refer to your policy schedule of benefits as to what the percentages are.

Coinsurance Due – This is the percentage of the allowed amount that you are responsible to pay after the deductible has been met. The percentage you owe may be higher for doctors or facilities out of the network. This amount may also be applied to the out of pocket maximum to be met each year.

Patient Responsibility – This is the total amount you are responsible to pay the doctor or facility. This amount includes the deductible as well as coinsurances due.

Remark Codes – Indicates if any services have been denied or are not covered. These are usually numbers or letters with the explanation of the code found either on the bottom of the page or at the end of the explanation of benefits statement.

Account Summary – This provides current information as to the amount of the deductible and coinsurance met as of the date of the explanation of benefits statement.

Although the American Medical Association (AMA) states that the error rate of health claims processed by health insurance companies has dropped from 20 percent in 2010 to 7.1 percent in 2013, this figure is still significant considering that millions of claims are processed each year. Are you able to determine if any of your claims are included in this percentage?

Understanding these EOBs can be not only confusing but frustrating as well when trying to determine what deductible amount is remaining for the year, what amount was applied to the annual out of pocket maximum and the patient responsibility due, if any, to the doctor or facility. This is especially true when receiving services from an out of network doctor of facility. Charges for services rendered by an out of network doctor or facility typically are applied to a higher deductible and higher annual out of pocket maximum.

Fortunately there are companies that staff Claims Assistance Professionals (CAPs) who can analyze these statements for you. At Medical Claim Service of Southwest Florida, we strive to make sure that your claims are processed accurately so they are not part of the 7.1 percent error rate. By making sure your claims are processed correctly, you will also avoid overpaying for medical services you received. If you desire peace of mind knowing that each EOB you receive has been reviewed thoroughly and accurately, please contact our office. Our staff will discuss the technique we use to review your EOBs and inform you of the correct patient responsibility due for each medical bill you receive.