A bill is not an Explanation of Benefits: do not pay yet

Do not pay a provider’s bill until you have matched it to the statement from your plan. That statement is called an Explanation of Benefits (EOB). It says what the plan paid, what it refused and what you may owe. The bill is only the provider’s request for payment, and the two can disagree.

If a clinician you did not choose treated you at an in-network hospital or surgery center, federal law may limit what you owe: see surprise bills and use the surprise bill checker.

What this means

An EOB is not a bill. It is the plan telling you what it did with a claim. A provider’s bill asks you to pay.

Bills and statements disagree for ordinary reasons. The provider may bill you before the plan has processed the claim. The plan may have denied the claim, so the provider bills you the whole amount. The provider may have billed the full charge instead of the plan’s allowed amount. A code may be wrong, or the claim may have been sent twice. A bill higher than the statement is a question to ask, not a debt to pay.

What to do

1. Find the matching pair (your step). Match date of service, provider name and claim number on the bill and on the EOB. If you cannot find an EOB, log in to your plan’s website or call the number on your card and ask for the claim status.
2. Read the “you may owe” line. The EOB decoder and how to read an EOB show where it is. That is the plan’s figure for your share.
3. Compare the two amounts. The bill and statement reconciler lays them side by side. If the bill is higher, write down the difference.
4. If there is no EOB yet, wait and ask. Call the provider: “Has this claim been sent to my plan, and when?” Call the plan: “Has it been processed?” Ask both to note it on the account. Do not pay until the plan has decided.
5. If the EOB shows a denial, work out which kind. Denied, rejected or your share separates the three. A denial can be appealed. A rejected claim usually needs a correction. See coding and billing errors for the paperwork kind.
6. Ask for an itemized bill if the charges are unclear (your step). Use the itemized bill request. We found no general federal law that gives insured patients an itemized bill. There is a right under the Health Insurance Portability and Accountability Act (HIPAA) to see a provider’s billing records, and many states have their own rules.
7. Ask the billing office for a hold in writing. Use the bill hold request. Ask them not to send the account to collections while you sort out the claim. Keep the reply.
8. Pay only the share you have checked. If the EOB and the corrected bill agree on what you owe, you can pay it. Do not pay an amount your plan may still owe.

What the billing office may say, and what to say back

“Insurance did not pay, so it is your responsibility.” Please send me the EOB showing that. If the plan denied the claim, I am going to appeal. Please hold the account in writing while I do.

“The EOB is only an estimate.” Please send me the account statement with the plan’s payment and allowed amount, and the itemized charges.

“You must pay today to avoid collections.” Please give me the date in writing and the name of a supervisor. I am checking the claim with my plan.

Watch for

• Surprise bills. For emergency services, for out-of-network clinicians at in-network hospitals and surgical centers, and for air ambulances, federal law limits what you can be billed to in-network cost sharing. Ground ambulances are not covered by that law. See surprise bills and ambulance bills.
• Your deadline keeps running. A hold does not extend your appeal deadline. Check the date on your notice, which controls.

If you have Original Medicare

For Original Medicare the statement is called a Medicare Summary Notice, and it is not a bill either.

• A signed Advance Beneficiary Notice. In Original Medicare, a provider gives this form when it expects Medicare to deny payment, and its purpose is to move possible financial responsibility to you. If you signed one, read it before you decide what you owe.
• Paper arrives slowly. Original Medicare mails the paper notice every 6 months, and the 120-day appeal clock runs from the notice. Check claims in your online Medicare account sooner.

The rule

For Original Medicare only: the Medicare Summary Notice is the written notice of the initial claim decision sent to a person with Original Medicare. It must give the reasons for the decision and explain how to ask for a redetermination. It is not a bill. See Code of Federal Regulations (CFR), title 42, section 405.921.

What next

• The bill while you appeal: how to handle bills for months, not days.
• Get an itemized bill: why it helps and how to ask.
• Hospital financial assistance: a way to lower a hospital bill whatever the plan decides.