Health Insurance Costs: What Do I Owe the Doctor?

Editor’s note: This is a special post by our Customer Service VP, Gail Levenson

I am a health insurance producer in New Jersey and I get this question all the time.  A patient receives a bill and wonders why the doctor is billing them.  The best way to keep track of what you owe your healthcare provider is to keep the Explanation of Benefits (EOB) that is sent to you by the insurance carrier each time you see a provider.  Instead of opening up the envelope and discarding the papers inside take the time to look at them and you will see that this document tells you what you owe your doctor and why.  By the way, for most carriers you can also get your EOB online at member services so you don’t even have to wait for the mail.

The EOB will contain the following information:

• Name of the Insurance Company
• Subscribers name and address
• Patient’s name
• Provider’s name
• Provider’s tax ID#
• Claim date of service
• Total billed charges
  • the amount the provider sent to your insurance company
• Allowed amount
  • the payment a provider has agreed to accept for the service under the terms of a negotiated contract with the insurance company.  This amount applies to in-network providers only.  The allowed amount can also be the maximum the insurance company will allow for a specific service.
• Discount amount
  • the amount the insurance carrier adjusts the bill because of the negotiated rate agreed upon between the provider and the carrier.  This is for in-network providers only.
• Copays and CoInsurance
• Deductible amount
• Patient responsibility amount
• Total payment and to whom it was paid
• A remark section
  • The patient responsibility amount is what you owe the provider.  Be aware that some EOB’s include the copay, coinsurance and deductible amounts and some don’t so it is up to the subscriber to know what they already paid the provider and deduct that amount from the patient responsibility amount if necessary.

Learning to read and use the EOB will help you keep track of your payments to your providers.