How to Understand a Prosthetic EOB and How Much Your Prosthetist Actually Gets Paid
EOB, or an Explanation of Benefits, is a document sent by your insurance company weeks or months after redeeming a healthcare service. This form states either your health insurance company shouldered all the costs or if it was an out-of-pocket expense and a claim was filed. You should be getting an EOB if you're a private health insurance holder, employed and entitled to health benefits, or under Medicare. In a nutshell, your EOB gives you information on how an insurance claim for a health care provider was paid on your behalf.
EOBs are a good way for insurance companies and health care providers to provide transparency and information as to where the money went after your service redemption. This is also a way for companies to inform patients how much they still owe. Insurance providers such as Blue Cross Blue Shield publish sample EOBs on their website, so patients can familiarize themselves with the document and not get lost in all the information contained therein.
What's in my EOB?
A typical EOB will contain the following:
- Patient’s name
- Insurance ID Number/Policy Number
- Claim Number – think of this as a reference number for your claim
- Provider – health care provider that gave out the service: this can be the hospital, a clinic, laboratory, or a doctor who administered the service
- Service type – brief description about the service you received
- Date of service – when you received the service
- Charge or Billed Charges – amount your Provider billed your insurance company
- Not Covered Amount – money that your insurance company did not pay to your Provider. More details about this are usually written at the bottom of your EOB
- Total Patient Cost – amount of money you owe, also known as out-of-pocket expenses. Services that aren't covered by your insurance may be specified in this section.
Here's a sample EOB to give you an idea:
John D. is a 60-year-old man with type 2 diabetes and left below-knee amputation. He is enrolled in a Blue Cross HMO and sees his prosthetist every three months for a follow-up of his prosthesis. Six weeks after his last visit, John received an EOB with the following information:
- Patient: John D.
- Insured ID Number: 82921-804042125-00 – John's Blue Cross HMO Plan Identification Number
- Claim Number: 64611989 – the number assigned to this claim by John's Blue Cross HMO Plan
- Provider: Randy G., CP – the name of John's Prosthetist
- Type of Service: Left Below-Knee Prosthesis
- Date of Service: 06/21/18 – the day that John received his prosthesis from Randy G., CP.
- Charge: $3135.00 – the amount that Randy G., CP. billed John's Blue Cross HMO Plan
- Not Covered Amount: $1046.00 – the amount of Randy G., CP’s bill that John’s plan will not pay. The code next to this was 264, which was described on the back of John’s EOB as “Over What Blue Cross Allows”. Typically, the prosthetic facility where Randy G., CP works, negotiated a discount with Blue Cross.
- Total Patient Cost: Depends if your plan has a share of cost and whether you met your deductible.
- Amount paid to the provider: $2089.00 – the amount of money that John’s Blue Cross HMO Plan sent to Randy G., CP minus an unmet share of cost or deductible.
The Numbers:
Randy G., CP. is allowed $2,089 (her charge of $3,135 minus the amount not covered $1,046.00 = $2,089). Her prosthetic facility gets any share of costs or deductibles from Bryan and $2,089 minus any applicable share of cost or deductible from Blue Cross.
It's important to review your EOB carefully, as insurance companies may make mistakes and include false information which could lead to you being over billed. Double check with your insurance company or health care provider if you need them to clarify any jargon or have any questions about your EOB.
