Explanation of Benefits (EOBs) can be confusing and intimidating, especially when dealing with denials, adjustments, or unexpected balances. Understanding your EOB is crucial for ensuring you’re being paid correctly for the services you provide. This post will guide you through the key components of an EOB and how to interpret them.

What Is an EOB?

An EOB is a statement provided by a payer (insurance company) that details how a claim was processed. It is not a bill but a summary of what the insurance company paid, what the patient owes, and any adjustments made to the claim.

Key Components of an EOB:

1. Patient Information:

   • Includes the patient’s name, member ID, and claim number. Make sure these details match your records.

2. Service Information:

   • Lists the dates of service, description of services provided, and the amount billed. Check for accuracy against your submitted claim.

3. Claim Adjustments:

   • Any reductions in the amount billed, such as negotiated rates, coordination of benefits, or disallowed charges. Verify that these adjustments are correct and match your contract with the payer.

4. Amount Paid:

   • The total amount paid by the insurance company. Compare this with the expected reimbursement to ensure it’s accurate.

5. Patient Responsibility:

   • What the patient owes, including copayments, deductibles, or coinsurance. Verify that these amounts align with the patient’s coverage.

Common EOB Issues:

• Denied Claims: If a claim is denied, the EOB will list a reason code. Cross-reference this with your records to understand and address the issue.
• Underpayments: Sometimes, services are underpaid due to coding errors or incorrect fee schedules. Review the allowed amount and check for discrepancies.
• Missing Information: An incomplete EOB may be due to missing or unclear data on the original claim. Check for any missing or incorrect information.

Tips for Managing EOBs:

• Organize by Patient and Date: Keep EOBs organized by patient and date of service for easy reference.
• Review Regularly: Schedule regular reviews of your EOBs to catch and correct errors promptly.
• Communicate with Payers: If you find discrepancies, don’t hesitate to contact the payer for clarification or correction.

Conclusion:

Understanding your EOBs is key to managing your practice’s revenue cycle effectively. If you’re struggling to make sense of your EOBs or have questions about discrepancies, we’re here to help.

Need help decoding your EOBs? Reach out to us for expert assistance.