Medical bills can be overwhelming, especially if you weren’t expecting one or the bill costs more than you thought it would. They’re also hard to understand. Sometimes, you see line items and codes that only make sense to people working in healthcare or insurance.
Don’t worry – we’ll walk you through the basics. The more you learn about this process, the more confident you’ll feel when making choices about your care.
What goes on behind the scenes between providers and insurers
- After a medical visit, your provider’s office submits a bill (also called a claim) to your insurance company. A claim lists the healthcare services that were provided to you during the visit. The insurance company uses information in the claim to pay your provider for those services.
- After your insurance company pays your provider, it might send you a report called an Explanation of Benefits (EOB). An EOB is not a bill. It’s a document from your insurer that explains what it’s paying for, what it’s not paying for, and why. If you have Medicare, you may get a Medicare Summary Notice (MSN) instead. MSNs are like EOBs but have their own terms and explanations specific to your Medicare coverage.
- Your provider’s office might send you a statement. This is how much your provider billed your insurance company for the services you received. If you receive this statement before your insurance company pays your doctor, you do not need to pay the amounts listed on the statement.
- After your insurance company pays your provider, you may not need to pay anything at all. This means that all the services provided to you at the medical visit were covered by your insurance plan. It could also mean you’ve met your deductible. That is a specific amount you must pay before an insurance company pays a claim.
- If certain services were not covered by your insurance plan, or if those services cost more than what your insurance plan covers, you’ll have a “balance due.” A balance is the difference between what your provider charged in the claim and what your insurance company paid your provider. Let’s say your provider submits a claim for $100. But the insurance policy covers only $70. This means you’ll have a balance due of $30.
Keep in mind that not all insurance companies send EOBs. And not all providers’ offices send statements. You may receive one or the other or both.
Why the itemized bill is your friend
An itemized bill is a detailed statement from your provider. It goes into depth on the services, procedures, and supplies used during your medical visit. It breaks down the cost for each item. This is a good thing because you can compare the itemized bill to the EOB. Then you can confirm whether the charges your provider made in the claim are correct.
As a patient, you have the legal right to get an itemized bill. But you might have to request it. Here’s how to do that:
- Call the provider’s office or billing department.
- Share your full name, date of birth, contact information, and patient ID number if you have it.
- Politely ask for an itemized bill for your medical services. Explain that you would like a detailed breakdown of services, procedures, and supplies and how much they cost.
- Specify how you want to receive the bill (email, fax, mailing address, or through your patient portal).
- If you don’t receive the bill within 1-2 weeks, follow up to check on the status of your request.
Medical bill errors to watch out for
- Incorrect dates. Make sure the day you went in for the medical visit on the EOB and statement match.
- Incorrect patient information. Double-check your personal information, including your name, contact information, billing address, and insurance details.
- Duplicate charges. Make sure you are not being billed twice for the same procedure, medication, or service.
- Inflated quantities. For example, a coder accidentally adds an extra 0, and you end up being charged for 100 pills instead of 10.
- Unbundled fees. When multiple services happen at the same time, like a physician’s exam before an endoscopy, they are bundled. Unbundled fees happen when bundled events are coded separately and not together.
- Incorrect codes. Coding errors happen all the time. That’s why it’s important to double-check the codes on your itemized bill. The easiest way to search for them is to use the Medicare Code Lookup tool. Enter the code on your bill into the tool and select “All Modifier.” Then, click submit for an explanation of the code.
You found a mistake – now what?
If you find any errors, document them.
Ask your provider for a copy of your medical records. See Medical Records: Why They Matter and How to Request Them.
You shouldn’t get a bill for anything that isn’t documented in your records. If that happens, talk to your provider’s billing department.
If that doesn’t work, contact your insurance company. The insurer might be able to fix billing errors directly with your provider.
If that doesn’t work, and you’re still having a tough time, take a deep breath. You’ve got this!
Many states have Consumer Assistance Programs (CAPs) that help patients with health insurance problems. CAPs offer direct assistance by phone, direct mail, email, or walk-in locations.
You can also get help from a patient advocate. They know the ins and outs of the healthcare system and can advocate on your behalf. Visit the Patient Advocate Foundation or call 800-532-5274 to learn more.
We understand it’s not always easy navigating healthcare. Fortunately, that’s what MediFind is here for, whether that’s finding a good doctor that takes your insurance, figuring out how referrals work, or discovering new ways to tackle medical debt.
