Explanation of Benefits (EOB) Sample
As you read on the Reading and Explanation of Benefits page, the EOB can be the key to unlocking questions surrounding payment (or not) of medical services by your health insurer. It is also a great way to ensure that your healthcare provider is billing you correctly.
Next, we want to analyze an additional EOB form. These is another actual EOB for services that didn't pay quite as cleanly as the other example. This is representative of everyday issues that you may find when you are dealing with your insurance company or medical provider.
In the example above, there are three charges. One for an Office Visit, and two identical charges for Medical / Surgical Supplies. If you follow each charge from left to right, you'll see that the $148 office visit charge translates into a provider discount and a $122.31 payment from the health plan, and all that is left over is a $20 copay for the patient. Both Medical/Surgical charges, however, are denied. Column C is titled "Pending or Not Payable", and there is a small "1" next to each charge. On the next page (not shown), the EOB explains in the corresponding "1" that orthotics (which is what these were) are not payable as part of this policy. As a result, the full price of $224 x 2 becomes part of the patient responsibility.
Research what that '1 was referring to was crucial. An astute patient would want to ensure two questions are answered: First, did my provider accurately bill the insurer for what he/she provided me as a medical service? Second, did the insurer accurately deny this charge per my specific plan?
Let's assume that both of those questions check out with satisfactory answers in this case.
What could this patient have done? Given that the insurance was not going to pay for orthotics, they basically had three options: Not get orthotics and have painful feet, get orthotics and have to pay the bill for them (or run them through their Flexible Spending Account, or FSA), or ask the physician for a different course of treatment that would be covered. This patient, obviously, chose to get the orthotics, and hopefully he/she will be able to get reimbursement from their FSA.