Explanation of benefits
Around the time your incision pain is starting to ease, you’ll have to start dealing with the headache of financial paperwork. In addition to the bills you receive from the hospital and your providers, you should automatically receive a document called an explanation of benefits (EOB) from your insurer. (If you don’t, call your insurer to request it.) The EOB is not a bill. Do not pay it, but read it carefully, because when you do ultimately have to pay your medical bill, it will help you understand how much you are paying for what – and why.
Although EOBs will vary slightly among insurers – and may be more complicated if you have secondary insurance – most will contain this standard information:
“Date of service” is the date you had the procedure for which your insurance is being billed. One bill may have several dates of service if you were in the hospital for several days.
“Procedure number” is simply an assigned number to your procedure. The hospital or physician must provide this to the insurance company for reimbursement.
“Description” is an explanation of the service for which the hospital is requesting payment.
“Amount submitted” is the dollar amount the hospital charges for the procedure. Most insurers will pay a specified percentage of the going rate in your area (called the “reasonable and customary” charge). If your doctor charges more than that – even if your insurance claims to pay 100 percent – you may be responsible for the difference.
“Amount approved” tells you the dollar amount the insurer approves for surgery. Ideally, this would be the same figure as “amount submitted.” If your doctor or hospital charge more than what is customary in your area, however, the amount approved by your insurer could be less.
“Applied to deductible” – if you have one – is the dollar amount (deductible) you’ll have to toward your care before your insurance starts paying its share. If you have not paid the deductible in full prior to your hospitalization, the amount you will need to pay toward the deductible will appear here.
“Patient payment" is the amount you will need to pay. In some cases, this will include what you owe toward your deductible along with a percentage of the remaining charge. If your insurance has a discount for preferred providers and you use a preferred provider, the amount may be paid in full.
“Insurance payment” is the amount your insurance will pay for each procedure.
