The billing process for healthcare services for a patient can sometimes seem complex and overwhelming. Your insurance provider is a good place to start for understanding the claims (or bills) that have been submitted by providers for your episode of care. For example if a patient has a surgical procedure they will likely have multiple claims submitted to their insurance by the facility, radiologist, anesthesiologist, surgeon and pathologist. Each claim will be processed by the patient’s insurance and summarized in what is called an Explanation of Benefits. The insurance company will submit a copy of the explanation of benefits to the patient for each claim submitted.
The Explanation of Benefits is Not a Bill but instead a summary of what was submitted by the provider and how the insurance is processing the claim. Your provider in many instances will be contracted with the insurance and the charges submitted by the provider are discounted based on your insurance plan. The Explanation of Benefits shows first the charges submitted, the applied contractual discounts and the amount after discounts which is often referred to as the allowable.
Often the Explanation of Benefits has a section that reads “Patient Responsibility” or “Amount Owed by Patient” Remember this is your insurance’s interpretation of what is owed based on information they received from the Provider. Providers also receive this Explanation of Benefits and it is used by the provider to see if what they submitted was accurate. Remember this is not a bill and only your provider will send you a bill not the insurance.
