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What is an EOB? And why it is not a bill.
OPENING
Your insurance company sent you a document headed Explanation of Benefits. It has dollar amounts on it. It looks a great deal like a bill.
It is not a bill. You do not pay it. Nothing is due.
But it is the single most useful piece of paper you will receive about your care, and almost nobody reads it properly. Here is what it is actually for.
WHAT IT IS
An Explanation of Benefits is your insurer's account of what happened after your provider sent them a claim. It says: this is what the provider charged, this is what we agreed to pay, this is what we actually paid, and this is what is left for you.
It arrives from your insurer. A bill arrives from your provider. They are two different documents, written by two different companies, and they do not always agree.
THE FIVE NUMBERS THAT MATTER
Every EOB has the same five figures, whatever your insurer calls them.
Amount billed. What the provider asked for. This is almost never what anyone actually pays.
Allowed amount. What your insurer has agreed the service is worth under its contract with that provider. The gap between billed and allowed is often enormous, and if the provider is in your network, they are not allowed to charge you the difference.
Plan paid. What your insurer actually sent them.
Your responsibility. What is left for you: your deductible, your copay, your coinsurance.
Not covered. Anything the insurer declined to pay for, usually with a reason code beside it.
That last figure is where the arguments live.
WHY THIS DOCUMENT IS WORTH KEEPING
Here is the part almost nobody is told.
When your bill arrives, put it next to the EOB for the same date of service and compare them. Your responsibility on the EOB should match the amount on the bill.
When it does not, one of them is wrong, and it is worth finding out which.
Common things this comparison catches:
- The bill charges you more than the EOB says you owe
- The bill charges you for a service the EOB shows the insurer already paid in full
- You are being billed the difference between the billed amount and the allowed amount, by an in-network provider, which is generally not permitted
- The service was never submitted to your insurer at all, so no EOB exists for it
- The same service appears twice, once on each document, from two different providers
IF THE TWO DOCUMENTS DISAGREE
You are allowed to ask about it. Start by requesting a full itemized bill from the provider, because a summary bill will not show you enough to argue with.
Then read the two side by side, line against line.
Most people never do this. The Commonwealth Fund surveyed 7,873 US adults and found that 45% of insured adults were billed for a service they believed their insurance should have covered. Fewer than half of the people who hit a billing error or denial challenged it, mostly because they didn't know they had the right to. Of those who did not challenge a billing error or denial, 54% said they did not know they were allowed to.
You are allowed to.
WHAT AN EOB WILL NOT TELL YOU
It will not tell you whether the codes on it are correct. It will not tell you whether the provider billed for something that never happened. It will not tell you whether the same procedure was billed twice by two different companies who were both in the room.
For that, someone has to read the itemized bills against the EOBs, line by line, across every bill from the same treatment.
That is what our bill check does. Every bill from one episode of care, checked together against your EOBs, in plain English, for $49. If we find something, the dispute package prepares the letters to do something about it.
FREE, AND NOTHING UPLOADS ON THIS PAGE
This is a guide. We do not ask you for your EOB, your bill, or any detail of your situation to read it. Nothing here is stored.
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