I had a routine checkup a few weeks ago and I got my explanation of benefits/bill from my insurance provider. It’s split up into three different documents for reasons I can’t determine.
Document 1 has one line item: One unit of “Medical Services” for ~$500. The “Provider Responsibility” (whatever that means) knocks $200 off that and I am responsible for the rest.
Document 2 is longer at 12 line items. The first being “Surgery”. I’m reasonably certain that I didn’t have surgery so who knows what that’s for. It’s for $31 and I am responsible for $8 with my nice provider taking $23 of the responsibility. The rest of the 11 line items are for “Lab Tests”. They are for various amounts and I owe nothing on them. Except for the last one. It cost $8, my provider is nicely covering $3.62 leaving me the princely sum of $4.38. Why? Who the hell knows?
Document 3 is two lines of more “Lab Tests”. Why a third document? Again, who the hell knows? But luckily I don’t have to pay anything for either of these.
The Provider is your insurance company. The Explanation of Benefits is not a bill. You’ll get a separate bill from the clinic/hospital you had the services performed at. That bill should have the total charges minus what the insurance paid leaving you with what you owe. What you owe on that bill should match the amount that the Explanation of Benefits says you owe.
I wouldn’t pay them anything, at least not yet. Supposedly an annual physical is covered under the new health care law. I didn’t pay my usual copay for my last physical.
What he/she said. The notice from the insurance company should say “THIS IS NOT A BILL” somewhere on it. In any event, you owe any monies listed to the doctor’s office, clinic and/or testing lab that actually carried out the procedures, not the insurance company.
Every entity involved in your treatment bills separately. That’s just how our wacky medical reimbursement system works. A couple years ago, I had a series of treatments for a difficult kidney stone, involving maybe a dozen separate medical entities. I ended up with a sheaf of bills, and not-a-bills, an inch thick.
The good news, if there is any, is that you may never be billed for some of the smaller (<10 bucks) items. Not worth pursuing, I guess.
Did you have anything done at the routine checkup that wasn’t a routine checkup? Was any blood drawn? Any biopsies taken? Did the doctor put anything (finger, instrument) into your body?
Did you mention anything…anything at all being wrong with you?*
Assuming the answer to all these questions are no and you basically just had a routine checkup, I would wait for the bill from the doctor’s office. Sometimes there’s some back and forth between them and the insurance company and you ‘hear’ bits and pieces of the conversation. IME, it’s best just to stay out of it until they send you an actual bill THEN call the doctor’s office and tell them you didn’t have surgery or labwork etc and let them straighten it out or explain it to you.
*It’s probably not the case here, but I’d seen examples where someone goes in for a ‘well visit’ that should be free or cheap but mentions something that’s been bugging them and even though no diagnosis was made and it wasn’t even discussed, it was coded as a consultation and the visit became much more expensive.
The “Surgery” item is probably the venipuncture, or the actual poking a needle into your arm to collect blood.
Why that gets broken out as a separate component of what the average person would call “lab tests” I don’t know. It’s rather hard to do a complete blood count (CBC) without drawing some blood.
As for the odd amounts the OP owes, some of that is based on the terms of your heath insurance plan: copays and deductibles, etc. The rest represents volume discounts that have been negotiated by the insurance carrier with the service providers.
Medical billing language is like Mandarin Chinese. You can learn to read and understand it, but it doesn’t come easy.
Definitely never pay an amount on an EOB. It’s not uncommon to receive several EOBs on the same set of services before you receive an actual bill. There is considerable dickering back and forth between the physician’s office and the insurer that often results in price adjustments. When they are done with the process, you’ll get an actual bill for anything that remains. That is the amount you must pay, and it will come from the medical provider, NOT from the insurer.
Most of this is about the opacity. For example, the Lab Tests. There’s no excuse for each line item to be just Lab Test. The insurance company obviously knows what they are because they have different prices and they were able to deny coverage for one. It should say what test it is, so at can I at least tell if it is a mistake or not.
My husband recently had back surgery, and I think we’re finally done getting bills - hospital surgeon, anesthetist, radiology.
What kills me is looking at the amounts - relying on memory here, I think the surgeon’s bill was in excess of $12K. BC/BS negotiated it down to a fraction of that, which they paid, and our share was around $300-ish. But if we didn’t have insurance, we’d have been on the hook for the full $12K!! Similar inanity for the other providers.
I understand it, but I don’t. It looks as if the various providers are trying to maximize profits on the backs of the uninsured or underinsured. I don’t begrudge anyone a fair profit, but there’s something not quite right here that I’m missing. I’m sure it’ll all be better when I’m Medicare age… <she said, snarkily>
That’s usually for privacy. If you call the office (again, after you get the final bill, don’t jump the gun) they’ll give you the exact breakdown of what each test is.
Ya know, they ‘say’ it’s for privacy, they say it’s so that if someone else in your house opens the bill all they see is ‘lab test’ or ‘office visit’ but that’s it. And yes, it does give your teenage daughter a way to get checked out for something without mom knowing what it was. But I have to wonder if it least part of it is also so that people pay for incorrect things without looking into them and/or don’t ask questions about things (even if they’re right) just because they don’t understand them.
I’m guessing mostly the privacy thing, it does make sense, but I know there’s been times where I’ve said ‘what’s this $13 charge…whatever, I’m sure it’s right’ and paid it just because it’s not worth spending a half hour on the phone and then waiting a few days for the mail to find out what it is.
I have a friend that works in the medical industry that asks for a detailed bill for every hospital visit and has found that most of them are wrong in one way or another. She also, while she’s in the hospital, keeps track of everything that’s being done so she has some reference.
But only so far… they’re not going to break it out with sub-charges for each individual test or anything. On your own personal bill, you’ll probably see something like a CBC (complete blood count)with differential, CMP (Complete Metabolic Panel) and Urinalysis on your usual physical EOB, as those are the actual billable units, even though there are lots of individual measurements lumped under the same blood draws and pees-in-a-cup.
EOBs are more to detail what’s covered, and at what negotiated rate, and what you’re on the hook for, etc… The actual bill should call it out a little more accurately, likely with CPT codes that you should be able to look up online.
The reason they might call it a “lab test” is for privacy reasons; you, as the subscriber might want to know that you’re being charged for a lab test your wife got, but as far as the insurer and medical provider are concerned, WHAT that particular lab test is about is between you and her, and not for them to disclose.
When I get bills from my doctor’s office, they aren’t bills, but statements. They list a date of service, some useless category and an amount. Why they are unable to provide an itemized bill is beyond me.
Expanding on what El Kabongsaid, I suspect the three documents are related to three distinct entities entitled to payment. The doctor (or his practice PC) is one, the hospital or clinic (providing facilities, nursing and technical staff, etc.) is another, and the lab a third.
The lab doesn’t care where you get the blood from. They aren’t drawing it, so they don’t get paid to draw it. The hospital (phlebotomist, using hospital-provided materials and facilities) does.
Just speculation, but that’s how I’ve seen the breakdowns before.
Pretty much for the reason(s) stated above. Privacy. You might not want someone else in your household (in general, maybe not in your specific case) knowing what was done, tested, discussed, biopsied, checked, removed, looked at etc, while you were at the doctor.
A simple phone call is usually all it takes to get the more detailed information.
I have never seen a bill from my GP or from a specialist. It is all covered by the insurance. My GP and specialists all get paid directly by the insurance company with no haggling, no problems at all. For the doctor, its a very simple billing procedure for patient visits and medical services. I don’t pay anything for medically ordered lab tests either. Or for visits to Emergency (at any hospital). Or hospital stays.
I do have to pay the doctor directly for “extra” services, such as sick notes, forms he needs to fill out for employment or other special medicals, telephone consultations, home visits and some other things.
The only bad part is that I may have to wait a bit for non-urgent surgery like knee surgery. Any also, a poor person will get treated the same as me, and might even get in to emergency before me, if they are medically triaged as needing urgent treatment. I can’t buy my way to the front of the line. C’est la vie, I can live with that.