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What is an EOB?

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  • Written By: Malcolm Tatum
  • Edited By: Bronwyn Harris
  • Last Modified Date: 24 October 2016
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    Conjecture Corporation
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An EOB is a document issued by an insurance provider to a client as an explanation of benefits as they relate to the terms of the insurance coverage. Most often, the insurance explanation of benefits has to do with recent treatments administered by a physician or healthcare facility. The EOB details the treatments that took place, the portion of the cost that is covered under the terms of the policy, and the amount remaining for the patient to pay directly to the healthcare provider.

The insurance EOB serves several useful functions. First, the document helps to create a documented trail of all actions taken in regard to a specific medical claim submitted by the attending physician. This helps the patient and the insurance provider to establish and maintain a history of all types of medical treatment the individual has received since the policy was initiated.

For the patient, an EOB makes it easier to keep up with the accounting process as it relates to medical expenses. The medical explanation of benefits clearly defines the total billed cost for various medical services, the amount covered by the insurance provider, and the amount remaining for the patient to pay. This leaves no question in the mind of the patient as to the amount that is still owed on the medical debt.

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Most insurance providers also include information related to the reason for paying or denying a line item found on the EOB. When payment is not extended on a particular item, there is normally a field where an explanation for the action is detailed. For example, the explanation may be that the patient has not yet met the deductible associated with the coverage, so no payment was issued to the healthcare provider. If the patient has met the deductible and terms of the policy allow the provider to pay a fixed percentage of the outstanding balance, that is also included in the detail. Information of this type is very important, especially if the patient wishes to appeal the decision of the insurance provider.

Just about any medical EOB can be thought of as a comprehensive health benefits statement, effectively providing the patient with a simple document that can easily be cross-referenced with the terms and conditions found in the health insurance policy. Today, many providers offer customers the opportunity to receive electronic copies of the document via email, as well as the more traditional approach of receiving a hard copy through the local postal service.

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shell4life
Post 5

@Oceana - My husband has that same insurance! We have yet to visit the hospital, and hopefully we won’t have to, but I’m glad we have that option.

Another portion of the plan is for regular doctor visits. His insurance gives him $1,000 in an account. Any time he goes to a doctor, the cost is deducted from that account, so he does not have a copay.

He always receives an EOB in the mail a month or so after a visit letting him know how much the trip cost and the amount remaining in his account. I’m sure this would not be a good option for someone with a serious condition requiring frequent exams, but for us, it works well.

Oceana
Post 4

@OeKc05 - Isn't that just terrible? Be glad that you had insurance, though. Can you imagine what your bill would have been without it?

My husband has Blue Cross Blue Shield of Arkansas, and with his plan, the maximum amount he can be responsible for on a hospital bill is $5,000. That sounds like a lot, but if something drastic happened and he had to be in there for a week or more, the bill could easily run into five figures.

We could have gotten a plan with a lower deductible, but it would have cost more per pay period. Since we are both in pretty good health, we are going to stick with this one for now.

OeKc05
Post 3

I got an EOB from my insurance, Blue Cross Blue Shield, after an emergency room visit for an allergic reaction to some medication. What upset me is that the doctor didn't do anything but say, "Yep, you've had an allergic reaction. Take Benadryl and keep ice on it." Yet, even with partial payment by my insurance, I still owed $500.

Not only that, I got a couple of separate bills. One was from the doctor, and the other from the hospital. I could see from the EOB what was billed by each one, but that didn't make me any happier. I didn't even stay overnight, yet somehow, my bill took almost my entire paycheck to cover.

JaneAir
Post 2

@JessicaLynn - A lot of people find EOBs and other medical billing related correspondence hard to understand. However, there is help!

Many insurance providers give explanations of their EOB forms on their websites. Simply go to the website and search for "EOB" or "Explanation of benefits" and usually you can find something that will explain it to you. Many websites even have a sample of one of their EOBs with written explanations on it. You can sometimes download this as a PDF file and keep it for next time you need help reading an EOB.

JessicaLynn
Post 1

An EOB is useful I'm sure. But I feel like if you're not in the medical field EOBs are kind of hard to understand. A lot of the terms that are used are medically related terms and the form is usually set up in a way that makes no sense to me!

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