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Health Care Fraud & You

What You Can Learn From Your Explanation of Benefits Statement

 Darren Greenwood/Aurora

You should carefully review your EOB every time you receive it.

Your health insurance company sends you an Explanation of Benefits, or EOB, to let you know that it has processed a claim for payment from a health care provider. Many insurance companies also let you check your account activity online.

You should carefully review your EOB every time you receive it. Your EOB provides information about the health care services you have received, how much your insurance company has paid for your health care and any charges that are not paid for by your insurance. An EOB is not a bill, but it may explain how much your health care provider can bill you.

By understanding what's in your EOB you can avoid spending too much for your health care. You can also look for billing errors and question anything you don’t understand or just think is not right.

Every insurance company’s EOB looks a little different. It may take a bit of work to figure out what you can learn from yours. If you have questions about what something means, call the company’s customer service representative. The number to call with questions will be on the EOB.

What you should see on a typical EOB for a typical doctor’s visit

• Information about you: You’ll see your name and address, the name of the patient if you have more than one family member insured, and your policy or group number. If any of this information is incorrect, it could be a clerical error or, possibly, an unapproved use of your medical identity. There may be a claim number assigned to the visit. You will need your policy number or claim number if you have any questions about the claim.

• The name and address of the provider submitting the claim: This could be the doctor’s name, clinic, group practice name or referring doctor. The address you see could be where the billing office is located rather where you had your appointment.

• The date you saw the doctor.

• A brief description of the services provided: You may also see a five-digit number. This is the Current Procedural Terminology or CPT code used to describe the service the doctor provided. Your insurance company uses this number to determine how much it will pay your doctor.

• The fee your doctor billed your insurance company.

• The dollar amount your insurance company approved for the medical services you received.

• How much your insurance company paid your doctor for the visit.

• How much you may have to pay your doctor for this visit. This could include any deductible for the year, co-payments and any charges for services your insurance plan does not cover.

What you should look for on an EOB


• Make sure you saw the doctor on the date for the listed services. Compare the information on your EOB to any statement, bill or other papers your doctor gave you at that visit. Do the dates, services and codes match? If you don’t see the codes on your doctor’s bill, ask for a bill that includes them.

• Check that you're not being charged for services you didn’t receive. Be sure you're not being billed more than once for a service.

• The “reason” code explains why the insurance company did not approve some or all of a claim. For example, your doctor may need to submit additional information, or the insurance company may not cover that type of service.

• Check the difference between the “amount billed” by your doctor and the “amount approved” by your insurance company. The difference between these two amounts is the amount that remains unpaid. Most likely you are not responsible for this amount. Depending on your insurance plan, your doctor may have agreed to accept the amount approved and to not bill you for the difference. Your doctor must tell you ahead of time if you will be billed for the difference.

• Your EOB may also track how much has been paid toward your deductible or any catastrophic cap on how much you must pay in any plan year.

What you should do with your EOB

• If something doesn’t seem right about your EOB, contact your doctor. The error could be a simple clerical mistake.

• If you still have questions about your EOB, or there's something that your doctor couldn’t correct, contact the customer service number listed on your EOB.

• If you suspect fraud, contact the anti-fraud department of your insurance company.

• Your EOB may have entries from other medical providers. These could be for medical supplies and equipment, or services you receive as a patient in the hospital. If you see an entry for services or supplies you don’t remember receiving or your doctor didn’t order, check with the provider.

• Establish a place to store and file your EOBs. You’ll want to keep your EOB statements for at least a year. When you dispose of the older statements, shred them to help prevent medical identity theft. You don’t want information about you, your health and your medical policy numbers getting into the wrong hands.

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