How EOBs help employees understand their health care costs

An explanation of benefits statement, or EOB, is a document that health insurance companies use to explain the costs of recent health care claims to their members. Making sure employees carefully review and understand their EOBs is an important part of managing health care costs.

“For many people, EOBs can be somewhat confusing and difficult to navigate,” says Amber Hulme, Medical Mutual regional vice president for Central Ohio. “But by helping employees understand what’s in their EOBs, organizations can avoid overspending on health care.”

Smart Business spoke with Hulme about what’s generally included in an EOB, key components to pay attention to and why it’s important for employees to review and understand every statement they receive.

What is an EOB statement?

Some people might not know what they are called, but anyone who has been to the doctor has probably seen an EOB. Any time an employee, or one of their dependents, gets care from a doctor, hospital or health care provider, their health insurance company generates an EOB. It documents the claim and explains how it was processed. Many insurance companies also allow members to review their EOBs online.

Each insurance company sets up its EOBs a little differently, but the basics are relatively similar. They include vital information for the policyholder, such as name, address and policy or group number. They also will have the provider’s name, date of service and a description of the care the patient received.

The key information, of course, is the details of how the claim is being paid, as well as current deductible and coinsurance balances.

How are claim details usually shown?

When employees receive an EOB, it’s important for them to look for a few key pieces of information. The amount billed, for example, is the full amount the provider charged for the services. The allowed amount, sometimes called the amount approved, is the portion of the claim covered by the health plan.

When employees review their EOBs, they can tell whether the health care provider accepted the allowed amount as payment in full. If they did, the employee is only responsible for the deductible, copays or any coinsurance amounts that apply. Otherwise, they might have to pay the difference between the allowed amount and the full charges.

How can EOBs help employees avoid overpaying?

For a variety of reasons, employees might find out that the services they received weren’t covered — or at least not at the level they expected. The EOB will include codes that explain why the insurance company didn’t approve some or all of a claim. For example, the plan may not cover a particular type of service, or the services were done at a non-network provider. This is coded and explained in the EOB.

By reviewing EOBs for these types of situations, employees can make better decisions about their health care in the future. For example, they might try taking advantage of urgent care facilities in non-emergency situations. Or, make a habit of checking the network status of their doctors and health care providers before they schedule each appointment.

What else should employees know about EOBs?

Most insurance companies have guides to help employees navigate their EOBs, and organizations should make those available to employees. Employees should be able to recognize, for example, if they’re being charged for services they didn’t receive.

Finally, it’s a good idea for employees to keep copies of their EOBs for their records. Insurance companies can usually retrieve paper copies for several years, but online copies are also available. Medical Mutual, for example, keeps electronic EOBs for two years. And employees should always call their insurance company if they have any other questions about their EOBs.

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