Your EOB and Your Bill Don't Match: How to Compare Them

What the EOB shows

The EOB usually lists the provider, the date of service, the service code or description, the billed amount, the allowed amount (the most your plan will pay for a covered service), the insurance payment, the adjustment, the deductible, the copay, the coinsurance, any denial reason, and your patient responsibility (the share the plan says you owe).

HealthCare.gov defines the allowed amount as the maximum amount a plan will pay for a covered health care service. Your EOB may also call it an eligible expense, a payment allowance, or a negotiated rate.

Coinsurance is the percentage of the cost that you pay after you have met the deductible. A 20 percent coinsurance amount means you pay 20 percent of the covered service cost once the deductible applies.

What the provider bill shows

The provider bill usually lists the account number, your name, the provider name, the date of service, the total charges, insurance payments, adjustments, any previous payments, and the amount due.

The bill may be shorter than the EOB, and it may group several services together. If the bill is too general, ask the provider for an itemized bill (a detailed statement that lists each charge separately). The itemized bill gives you a better view of the dates, the service lines, the supplies, the medication charges, and the provider charges. Do not compare only the total balance. Match the same date of service on both documents.

The comparison steps

Use this order:

1. Match the provider name.
2. Compare the billed amount.
3. Compare the allowed amount.
4. Check the insurance payment.
5. Match the patient name and account number.
6. Match the date of service.
7. Check the adjustment or discount.
8. Check deductible, copay, and coinsurance amounts.
9. Compare the EOB patient responsibility with the provider balance.
10. Write down any difference before calling billing.

When the numbers do not match

If the bill asks for more than the EOB says you owe, start with the billing office. Ask whether the insurance payment, the adjustment, or the patient responsibility has posted correctly.

If the EOB shows the claim was denied, check the denial reason. HealthCare.gov explains that a person can file an internal appeal when a health plan will not provide or pay some or all of the cost for care that the person believes the plan covers.

If the EOB is missing, get it from your insurance portal or request it from your insurer. Do not rely on the provider bill alone when insurance was involved.

Questions to ask billing

When you call the billing office, ask direct questions and, when possible, ask for the answer in writing or through the billing portal so you have a record. Work through this list:

• Has the insurance payment posted to this account?
• Has the contractual adjustment posted?
• Does the patient responsibility match the EOB?
• Was this claim denied, paid, or still pending?
• Can you send an itemized bill for this date of service?
• Was this sent to collections?
• Can you place the account on hold while the insurance issue is reviewed?

Common mistake

The common mistake is paying the provider bill without comparing it to the EOB. A provider bill can arrive before your insurer finishes processing the claim, and it can also arrive after a claim is denied, corrected, or reprocessed.

Another mistake is assuming the phrase "amount due" means the same thing on every document. On the EOB, patient responsibility is the plan's calculation of your share. On the provider bill, the amount due is the provider's current balance. Those two numbers can differ when posting or claim processing is incomplete.