A Healthy Dose of Paperwork: Why it Makes Sense to Pay Attention to Your Health Insurer’s Explanation of Benefits Statement 

By Diane Kelley 

The issue of health-care reform has been under the microscope for some time now. Political leaders, physicians, health insurers and patients have all joined the debate, and in the months ahead there will be an increasingly spirited discussion about how best to expand insurance coverage, cut down on medical costs, and make healthcare more affordable for all.  In the short term, however, there are some important steps that consumers can take to gain greater control of their own health care, and to keep their medical costs in check.  

* Pay attention to the paperwork. Most people who have medical coverage are aware of the Explanation of Benefits (EOB) statement that they receive from their insurance provider after they visit a physician, undergo a medical test, or check in to a hospital.  The EOB details the cost of each visit and procedure, shows how much was paid by the primary or secondary insurance provider, and how much, if any, will ultimately be the financial responsibility of the patient.  If consistently reviewed, the statement can be a powerful tool for patients to monitor their coverage, ensure the billing accuracy of their medical providers, and gauge the parameters of their insurance coverage. To truly understand their health coverage, and to make sure that they are not being over-billed by medical providers, however, patients should make every effort to treat their EOB statements as useful tools, and not as formalities to be filed away. 

*When reading the statement, the first thing patients should do is to check for accuracy.  Make sure that the physicians and services listed truly reflect your medical visits, and check that your deductible was correctly applied.  Verify that all of your insurers were taken into consideration.  In many cases, patients with Medicare will see this coverage listed as a secondary insurer, and payment should be made accordingly.  If you have a secondary insurer, and the insurer is not listed, you may be billed by your physician in an amount that exceeds what you should actually pay. 

*Take action if there is a problem. If the EOB contains inaccuracies, or if patients have questions, the insurer can clarify issues, contact a physician, or help patients prepare with the right questions so that they can ask the physician’s office directly.  Patients should also understand and be willing to exercise their right to appeal.  If you do not agree with your insurer’s payment decision, you can ask that it be reviewed and reconsidered through an appeals process, and the EOB contains specific directions on how to pursue this route. 

*Retain your EOB statements for your records. This way, if there are future questions or appeals, you will be able to easily reference past activity. 

*Remember to check the EOB for educational messages that some insurers include. The statement may offer advice about cutting down on costs by always asking for generic vs. brand-name drugs.