Explanation of Benefits vs. Medical Bills

We’ve all been there—you recently visited the doctor, had a dentist appointment, or saw a specialist, and weeks later, you receive a document in the mail detailing the amount of money you owe. But it’s not a medical bill. This document is called an explanation of benefits, and it essentially is a report that shows what your insurance company is going to cover. We took a look at the journey from appointment to explanation of benefits to medical bill. 

The Patient Attends Their Appointment

The first step of the journey is the appointment. Whether it’s a routine checkup, surgical procedure, or your first time seeing a new specialist, the appointment is the point at which your information will be collected, both personal and related to the procedure or treatment, and recorded to later be used for billing. 

The Insurance Company is Billed

Once the appointment is over, the medical billers will work hard to send along the bill to the insurance company as soon as possible. The process isn’t always a fast one, but both the medical practice and the patient benefit from a fast turnaround time. Insurance companies require claims to be filed within a specified timeframe, usually 30 days, so the whole process could hypothetically be complete in a month or less. 

The Insurance Company Determines Coverage and Sends an Explanation of Benefits

When the insurance company receives the claim, they then examine the patient’s insurance coverage and determine how much of the procedure is covered. Coverage will vary from patient to patient and from plan to plan, but patients should have a good idea of what might be covered before their appointment. The bill may vary slightly from what they expected, but it shouldn’t be significant. Once the covered portion is determined, the patient will receive an explanation of benefits in the mail detailing what they will owe. 

The Insurance Plan Pays Their Portion of the Bill

After coverage is determined, the insurance company pays their portion of the bill to the doctor’s office. This is typically the last step that the insurance provider will be involved in.

The Doctor’s Office Bills the Patient for the Remaining Amount

This is usually the final step of the billing process. The healthcare facility that the patient received care at sends a final bill to the patient for the remaining amount. At this point, the patient has a specified amount of time to pay the bill. If they fail to pay the bill within the timeframe, they risk a visit from a collections agency. 

Explanation of Benefits 

Now that you understand how the process works, let’s take a more in-depth look at what an explanation of benefits is, and what you should do with it. You’ll receive an explanation of benefits in the mail before the actual bill arrives. When you receive your explanation of benefits, you’ll be able to see the service received, the amount covered by your insurance company, and the final amount owed. Although the explanation of benefits isn’t a bill, you should still save it until you receive the bill so you can verify that the two contain the same information. If you received multiple services, your bill will be itemized so you can see what you were charged for each one. Healthcare providers are typically the ones who submit insurance claims on behalf of the patient, but if for some reason the patient has to submit it themselves, they may not receive an explanation of benefits before they get their bill. If this happens, it’s important to wait until the explanation of benefits comes in the mail to ensure coverage was properly applied. 

Medical Bills

A medical bill is the final, official document the patient should receive in the mail following a medical appointment. The bill will contain a variety of information including the date or dates the services were received, a description of each service, the amount each service costs in full, the amount insurance is covering, and finally, the amount the patient owes. The bill will also state where the bill is payable to along with a deadline. Insurance companies typically allow generous timeframes for payments, but if a patient has a concern about meeting the indicated deadline, they can reach out to insurance and work something out. 

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Billing can be a complicated process for even the most experienced billers, but luckily, there are tools on the market that can simplify the process and increase accuracy. If you’re a biller in New York looking for a solution, it’s time to request a demo of our NY Medicaid billing software. Our demos are free and allow you to get a personal look at our product in action. If this sounds like the solution you’ve been looking for, book your demo today.