Not all claims are paid in full or some are denied completely, and there could be many reasons for this. Ensure that you understand the reason behind each payment and work to resolve any issues.

First, if there is a denial, it will show up on the Explanation of Benefits (EOB). The EOB shows you how much was billed, for which service, how much was approved, etc. Understanding the different parts of an EOB is an important first step.

Next, assess the services billed and make sure the items are paid correctly. Listed next are some possible EOB examples.

Different EOB Examples

Deductible not met

Consider:

  • Billed amount = $200
  • Discount = $45
  • Covered amount = $155
  • Deductible = $155
  • Insurance paid = $0

In this situation, the patient still has a deductible amount to meet. Although their insurance plan provides a discount and covers the remaining amount, because the patient has not met their deductible, they are responsible for the rest of the payment.

*numbers made up for the example

Out of network

Another reason the payments received may be unexpected is when the patient is out-of-network.

Consider:

In-network Out-of-Network
Billed Amount             $200 Billed Amount           $200
Discount                     – $45 Discount                   – $0
                                      = $155                                     = $200
Insurance Coverage    $100 Insurance Coverage  $100
Patient Pays                  $55 Patient Pays                $100

 

Here, the insurance payor might cover less than what you would expect if patient was in-network. Being out-of-network means your healthcare practice does not have a contract with the patient’s insurance provider. This may mean a lower plan discount rate or the insurance payor does not cover as much as if your practice is in-network.

Check to see if the patient’s plan is in or out-of-network with your healthcare practice. This way you won’t be surprised to see why a plan paid less than expected. In the new No Surprises Act, this becomes even more crucial as there could be penalties for billing out-of-network patients incorrectly.

*numbers made up for the example

Denials

There are also situations when a claim is denied completely. These can include:

  • The service billed is not covered by the insurance plan at all.
  • Accidentally billed the same service twice.
  • Missing information such as chart notes/documentation.
  • Time limit for filing/making appeals has passed.

Whatever the reason may be, the EOB also includes a column that refers you to a footnote explaining the reason behind the payment for each row. Understand these different issues and work towards making timely appeals.

Our billing experts have a deep understanding of the billing process and help to reduce errors and denials. If you feel your practice is overwhelmed with billing claims, reviewing EOBs, filing appeals, you can give us a call at (801) 719-1171 to learn more about how our services can benefit your individual practice.

Don’t have the time right now? Book an appointment for a free consultation when you’re available!