A few weeks after receiving medical care from a service provider in which health insurance was applied, you should receive an Explanation of Benefits statement in the mail or email. Although not a bill, the Explanation of Benefits will often note the amount that you may owe your provider. It also includes information such as: services received, the dates of service, your deductible, eligible and ineligible services, and your total out-of-pocket costs. If you note a discrepancy between the Explanation of Benefits and the bill from your service provider, it is important to let erroneous provider know.
Mistakes are common in medical billing, and many often go unnoticed because individuals do not go over their Explanation of Benefits. Below are 3 important reasons to check your Explanation of Benefits every time- even if your insurance covered the service in full. Premera has a great example of what an Explanation of Benefits looks like and explains how to read your bill. If you have a different provider, they might offer the same type of information catered to their document format.
Data and Coding Errors
Simple information that has been mistyped could delay processing of insurance claims. Check simple details, such as your name, the patient’s name (for dependents), date of service, insurance group number, etc. In addition, check the medical billing code for the services received. If your insurance has denied a claim for a procedure that should have been covered, make sure your medical service provider billed the correct code that matches the service received.
Double Billing or Inaccurate Billing
Double billing is most common during hospital visits, since they often require more supplies. Providers may bill for “kits” or “room fees,” which include a set fee for a bundle of services or supplies. However, sometimes itemized services or supplies are billed that should have been a part of the bundled fee charged. Check your Explanation of Benefits for bundled fees and compare what that bundle includes to fees that were individually itemized. Don’t be afraid to call and ask the billing department for clarification to the charges incurred.
Also, be on the lookout for services or supplies billed but never received. This also is more common in a hospital, due to the higher quantity of patients and complexity of billing for multiple items.
Balance Billing
Balance billing occurs when a service provider and an insurance company come to a contractual agreement on coverage for services, which caps the amount the insurance company will compensate the service provider for, depending on the service received. The difference, or balance remaining, between what is charged and the contracted amount cannot be billed to the patient.
Rich Newsome, Sr. Partner at Medical Malpractice Help says “Be sure to be vigilant about what will be charged versus what is actually charged.”