Training Primer EOBs

[Steve Verno]

What is an EOB?  We, in billing, have our own language.  EOB stands for Explanation of Benefits.  It is a document that details how the patient's claim to have their health benefit processed.  An EOB can also be called a remitance r Explanation of Medical Benefits (EOMB). A remittance could have multiple patients listed on it. 

Q:  Does an insurance company have to send a copy of the EOB to the doctor?
A:  If the doctor is NOT contracted or if the docor didnt accept assignment, then NO, the insurance company is obligated to let te paient know how the claim for health benefits were processed.

It is very important for the biller to look at the EOB/Remittance to see if everything on it is true, accurate, and correct.  Why? This is because the insurance company can make mstakes.  Some mistakes that you can find are:

a.  Wrong date of service
b.  Not your patient 
c.  Missing CPT Codes
d.  Downcoded CPT Codes.
e.  Wrong charges listed
f.  Provider discounts when there is no contract
g.  Missing reason codes

These mistakes can be very costly to your povider and you.  ANytime you find  mistake, and the mistake is with a payment, a denial, a missing code or a downcoed service, you should appeal the mistake. 

ERISA EOBs are regulated by Federal Regulation, specifically 29 CFR 2560.503-1.  The EOB is required to tell you why a service or benefit was paid the way it was, why it was denied, any rule or plicy that is why the ervice was denied. 

If your doctor is contracted, you need to make sure that the payment is exactly according to the terms of the contract.  If not, appeal the incorrect payment. 

Q:  How long do I keep the EOB?
A:  AN EOB is a unique document because it not only contains personal health information, but it is also a financial document.  Financial recors are kept accding to State or Federal Law.  Normally 7-10 years.  Many practices or businesses scan EOBs.  The scanned image is available at any time and doesnt take up any office space.  Scanned images do take up computer storage space.  Terabyte hardrives are now reasonably priced.  I bought a 1 terabyte hardrive for $99.00 

You also need to keep patient privacy in mind when using an EOB to send a claim to a patient's secndary insurance company. For example, if you have Blndie and Dagwood on the same EOB and a claim must go to Dagwood's insurance company.  You need to remove ay reference to Blondie on the EOB. 
Do NOT use white out.  This is because anything under the white out will come out when held up to a bright light such as in a scanner.