The most common cause of bankruptcy in the United States is medical expenses. If you’ve spent any time in a hospital or have dealt with a severe health issue you know how expensive it can get.

Even if you have health insurance, you can still struggle to pay off medical bills. Many insurance plans have high deductibles that can really put you in a bind if you or someone in your family has an issue.

It’s all very stressful, and that anxiety is compounded by complicated medical terminology and bills that don’t seem to make sense. You can ease some of that stress if you have a little more understanding about your medical bills and the terminology.

EOB or Medical Bill?

An EOB is a statement that you receive from your insurance company that lists your accepted treatments and medical services and shows your total coverage based on your insurance policy.

A medical bill is a full breakdown of the medical services provided. This bill will show the date of service, total service amount, the amount your insurance company has covered and paid, and lastly, the amount, if any, that you are responsible for paying.

Let’s focus first on insurance statements and their related terminology.

  • Explanation of Benefits. Explanation of benefits, or EOB, is a statement sent by mail from the insurance company. Contrary to what some may think, this explanation of benefits is not a bill. Instead, the letter shows the submission process of the claim to the insurance company according to the patient’s policy.
  • Deductible. A deductible reflects the dollar amount you, the patient, are responsible for paying before insurance pays for medical services.
  • Copay. A copay is a fixed fee put in place for the patient to pay for medical services. For example, one can expect to pay a copay for primary care physician appointments, lab testing, urgent care visits, and emergency room visits. The copay will vary depending on both your insurance company and the policy.
  • Out-of-Pocket Maximum. This amount reflects the maximum amount you will pay within a policy year before insurance will begin to pay 100% of your medical services.
  • In-Eligible Services. If you see “in-eligible services” listed on your medical bill, this is simply stating that your insurance policy did not cover a specific medical visit, test, or procedure.

Understanding Medical Billing Terminology

Medical bill terminology describes the amount a patient is responsible for versus the amount insurance has agreed to pay on their behalf. Insurance typically covers a portion of the costs, with the remainder required to be paid by the patient or sent to secondary insurance if one is available. But what does this medical billing terminology mean?

There are many components to know to understand a medical bill, so let’s break them down.

  • Date of service: this reflects the date on which you received the medical service or procedure.
  • Member: in this space, you will either see the patient’s name, whether you or a member of your family listed on your insurance policy.
  • Description: the description section summarizes the services provided, the procedure performed, and/or lab testing performed.
  • CPT codes: current procedural terminology, or CPT codes, reflect a five-digit number that directly corresponds to the service received. Medical billers use these to ensure proper billing for the performed procedures.
  • Charge: this price represents the total amount of the service provided. You are not responsible for paying this amount.
  • Adjustment: the discounted rate that your medical provider and insurance company approve and your insurance’s current payments for your medical bill.
  • Balance: this amount reflects the actual amount owed by you, the patient.

Correcting Your Bill

If you are one to diligently review a medical bill before sending the payment of the remaining balance owed, you are likely to spot an error or two throughout your review.

While it can be frustrating to receive an incorrect bill, remaining calm throughout your discussion with all involved will likely help your case in the long run.

The first step to correcting your bill is to request an itemized bill from your insurance company. This bill will reflect:

  • Date and time of services provided
  • CPT codes
  • Description
  • Total price
  • Adjustment
  • Amount due by the patient

Once you have received this and reviewed it, you will contact your medical provider’s billing department and request a representative regarding your bill. They will likely place you on a brief hold while they research the discrepancy or advise you of a specified time frame for the error to be fixed, typically 4-6 weeks.

If you cannot make progress with your medical provider’s billing department, you may file an appeal with your insurance company. They will be more than happy to help you with the error because if they don’t have to, they do not want to pay more.

Next, you will file an appeal with your medical provider’s patient advocate if you have not received the help needed.

As a last resort, if no one else has seemed to help correct the errors, you can contact your state insurance commissioner. You will be required to fill out an official complaint form and attach all documentation and paperwork to this form. At this point, you should consider contacting an attorney.

Bottom Line

Medical bills can create stress and confusion, but you do have options. If you need to dispute an invoice, you must take diligent notes of any conversations regarding your account.

Ideally, you would record the phone calls when you can do so. If you are sending anything by mail, ensure you keep a copy for your records as well. Ask a lot of questions and take a lot of notes that you keep in an organized location. Keep track of your insurance policy and stay informed about the terminology.

Also, don’t give up the fight.

© Fintactix, LLC 2022