Insurance 101

INSURANCE COMPANIES OR 3RD PARTY PAYORS:

If you have private insurance, most of your healthcare costs will be submitted to them for payment. But that is just the beginning. Your insurance company may pay all or none of your medical charges leaving you with none or some of the bill. These insurance companies including Medicare and Medicaid are referred to as 3rd party payors. When you incur a charge, which is submitted to your insurance, the insurance company then determines what they will pay. These are called benefits. The insurance company will provide you with an Explanation of Benefits or EOB to let you know what they will pay or not pay. An EOB is NOT a bill. It is, as its name implies, an explanation of why they paid your claim as they did. What specifically is an EOB?

You will receive a statement, which will be broken down into all the components of your bill and its coverage. Your EOB will usually contain:

  1. The date of service or DOS.

  2. A code indicating where the visit took place.

  3. The charge (the actual amount your doctor charged you and sent to your insurance company for payment)

  4. Contracted amount. This is where it gets tricky. It isn’t important what the doctor or lab or radiologist charges you. Your bill starts with the contracted amount. Each insurance company has a different contracted amount.

  5. Copay. Most private insurances expect the customer to pay a copay for the encounter. This is due at the time of service.

  6. The contracted amount minus your copay will result in your balance.

  7. Again, it gets tricky. Your insurance policy likely has a deductible. This is the amount you must reach before the insurance company will begin to pay your bill.

It is important to read and understand the EOB sent to you by your insurance company. The final column will state Balance Due. This is the amount you still owe your doctor. If you do not understand it or disagree, call your insurance company and ask. The phone number should be listed on the EOB.

Your other resource is the biller at Riverview Pediatrics. Our biller has seen hundreds of EOBs.

She will be happy to go over it with you or answer any of your insurance questions.