What to Do When Your Explanation of Benefits Does Not Match Your Bill

An Explanation of Benefits (EOB) is a document from your health insurance company detailing how a medical claim was processed, showing what the insurer covered and what portion you might owe. It is an informational statement, not a bill. A medical bill is the actual invoice from the healthcare provider requesting payment for services. Their misalignment can cause confusion. This article guides you through understanding and resolving situations where your EOB does not match your medical bill.

Identifying Discrepancies

When comparing your EOB and medical bill, a systematic approach helps pinpoint differences. Verify the patient’s name, policy numbers, dates of service, and healthcare provider names and addresses are consistent. Proceed with a line-by-line comparison of services or procedures, paying close attention to medical codes like CPT and ICD-10. Verify the “amount billed” on your EOB corresponds with the total charges on your medical bill. Cross-reference the “amount paid by insurance” and your “patient responsibility” for deductibles, copayments, and coinsurance on the EOB against what the medical bill requests.

Common Causes of Discrepancies

Discrepancies between an EOB and a medical bill often stem from administrative or coding complexities. Common issues include coding errors, where incorrect CPT or ICD-10 codes lead to inaccurate charges. Data entry mistakes, such as typographical errors in patient information or service dates, also contribute to mismatches.

Duplicate billing, where a provider mistakenly bills for the same service more than once, is another cause. Services not covered by insurance or denied due to lack of medical necessity can also lead to discrepancies. Pre-authorization issues, where required approval for a service was not obtained or was denied, can result in unexpected out-of-pocket costs.

Differences in patient responsibility may occur if deductibles, copayments, or coinsurance amounts are applied differently. Billing for out-of-network services can also lead to higher charges. Errors related to bundling or unbundling of services can impact final charges. Timing differences, where the EOB is generated before all billing adjustments are finalized, can create a mismatch.

Steps to Resolve Discrepancies

To begin resolving any discrepancies, gather all pertinent documents, including your EOB, the medical bill, and any supporting medical records or pre-authorization approvals. Having these materials readily available will facilitate discussions with billing departments and insurance representatives. This preparation ensures you have specific details to reference during your inquiries.

Your first point of contact should be the healthcare provider’s billing department. Clearly state the specific discrepancy you’ve identified, providing the patient’s name, date of service, and relevant claim numbers. Request an itemized bill, as this can often reveal additional details or errors not immediately apparent on the initial statement. Ask for a detailed explanation of why the charges on their bill differ from what is indicated on your EOB.

If the provider’s billing department cannot resolve the issue, or if the discrepancy appears to stem from an insurance processing error, then contact your insurance company. Be prepared to provide the claim number from your EOB and explain the specific mismatch you’ve found. Inquire about the denial reasons if a service was not covered, and ask if any additional information is needed from the provider to process the claim correctly.

Throughout this process, meticulously document all communications. Note the date and time of each call, the name and employee identification number of the representative you spoke with, a summary of the discussion, and any reference numbers provided. This detailed record-keeping is invaluable if further appeals or follow-ups become necessary. If initial calls do not lead to a resolution, understand that both providers and insurers have internal appeal processes, which typically involve submitting a formal written request for review. While actively working to resolve the disputed amount, consider paying any undisputed portions of the bill to avoid potential collection issues.