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What is an Explanation of Benefits vs. a bill?

They both say “amount you owe” on the bottom line, so which one should you pay? Here’s what you need to know about EOBs vs. Bills.


By Barb Breher
August 5, 2017

     


Explanation of Benefits... Do I pay for this?

Let's say you recently visited your doctor, and you're wondering how much that visit is going to cost. Then one day you get something in the mail that sort of looks like a bill – it even says "amount you owe" at the bottom. But it's missing the usual tear-off portion and return envelope. Confused? You're not the only one.

Most likely it's an Explanation of Benefits (EOB) from your health insurance plan. We get a lot of questions about EOBs from our members. Here's a little primer on why you got that EOB and what you're supposed to do when you get it.

Where does an explanation of benefits come from?

Should you pay it?

The Explanation of Benefits is not a bill so, no, you shouldn't pay anything yet. It's really just a report of what your insurance plan is going to cover, based on what the doctor has charged and what type of plan you have.

What to look for on your EOB

The important things to check are, first, the services you received and the date you received them. Next look for the provider responsibility, which is how much your insurance plan covered. If your plan has a deductible, copay, or coinsurance (a set percentage you each have to pay), it all gets figured into the equation. What's left is the "amount you owe."

What should you do with an EOB?

You should always save your Explanation of Benefits forms until you get the final bill from your doctor or health care provider. Compare the amount you owe on the EOB to the amount on the bill. If they match, that's the amount you'll need to pay. Keep in mind that often you will get more than one EOB if you received more than one type of service or treatment, or if you received treatment on more than one day. You may have a stack of several, which you should save. Your bill should itemize the services you received so you can see what was billed and what was covered for each.

What if you don't get an EOB?

If you are a member of a network or your doctor's office has your insurance information, most likely they can submit the insurance claim for you. But if they don't have that capability, you may have to submit the claim yourself. In that case, you may get a bill from your doctor or health care provider before you get an Explanation of Benefits.

Either way, don't pay your bill until you receive an EOB for that service. That way you can be sure your insurance company paid their portion and you're not paying more than you owe.

Of course, if you ever have questions about a bill or an Explanation of Benefits, you can always call Member Services at your insurance company for answers. They are happy to talk you through your EOB and help you figure out what you owe.

About Barb Breher

Barb Breher is a leader in the Member Services department at HealthPartners. She specializes in individual and family health plans. Barb loves helping members understand and use their coverage (it’s confusing!). When she’s not working, she loves relaxing and camping with her husband and two young daughters. Minnesota locals: she highly recommends Voyageurs National Park.

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