Medical Billing Questions

Have you every received a medical bill in the mail and couldn’t decipher it? Not to worry because you are among millions who cannot make heads or tails out of some of the jargon used on medical billing.

If you have medical billing questions, you should certainly contact your physician or HMO. Just in case, here are some tips on how to read these cryptic bills.

Once you visit your doctor, he submits his bill to your insurance company. It lists the services performed. The insurance company, in turn, pays the doctor for services rendered. After your doctor is paid, or in some cases before, you are send a statement which is called an Explanation of Benefits. It merely shows the date, doctor’s name, and services. Keep in mind, however, that the Explanation of Benefits statement is not a bill; it is a way for you to determine if the information on it is correct.

In addition to the explanation statement, you may also receive a statement by your doctor. This may also show how much the doctor paid your insurance company. Depending on the type of insurance company you are dealing with, you may have to pay for blood tests or X-rays to the company who performed these tests, and not your doctor. For example: You have an HMO wherein you pay $15.00 to your doctor every time you visit. On one visit, you may need a blood test. The company who actually performs tests on the blood will also send you a bill for $15.00. This bill should be paid to them directly.

There are instances in which you may find information on the Explanation of Benefits statement to be unfamiliar or duplicated. In this case, you should notify your insurance company and relate your concerns about the statement.

To basically boil this down for you, the Explanation of Benefits statement has the following information:

Member name (that’s you); claim number (which is assigned by the insurance company, and with which you can use to contact them if there are any questions);

Plan number (this identifies what type of insurance you have);

Member ID (this is the insurance company’s identification number assigned to you);

Date Paid (the date the insurance company sent payment to the doctor); Plan Sponsor (if your employer pays for insurance);

Patient ID (the insurance company’s identification number for you;

Patient (the person who received services);

Relationship (if someone other than you had services performed);

Provider Name (who provided the services);

Procedure Code (tells what type of procedure or service was performed);

Negotiated Savings (the difference between what was charged and what was paid by the insurance company);

Remark Code (in case the insurance company refused to pay for the services and the reason);

Total Payable (the amount the insurance company has paid to your doctor);

Deductible, Co-Payment (the amount you paid to the doctor);

Member Responsibility (the amount you owe the doctor or other service provider);

Check amount (the amount paid to the doctor);

Date of Service (the date you visited your doctor or service provider);

Total amount charged;

Charges not covered (additional services your insurance company may not cover you for).

In addition, if you have further questions about your doctor or services performed, you may wish to go here: where every question concerning doctor/patient ethics can be answered.