How Reviewing Medical EOBs Helps Prevent Medical Identity Theft

Quiz question: What’s one of the dullest things that arrives in your mail and one of the most important things to read for your health?

If you answered, “Medical Explanation of Benefits (EOB) statements,” you are correct. Whether they come by post or by online notice, EOB forms are about as much fun to read as tax forms and grocery store receipts. That said, they’re among the most important mail you receive because they can be clues to medical identity theft or billing errors. If someone else impersonates you to get medical treatment or uses your identity to commit medical fraud, you could lose your coverage or end up being stuck with huge medical bills. Not only that but if someone else’s medical information makes its way into your records, it could mislead doctors in ways that could threaten your life.

Reviewing EOB statements is the best way to spot and fight medical identity theft and to identify billing errors that could also eat away at your benefits. Here are the important things to look for:

• Patient information: Check that the name, address, etc. are all correct, whether the patient is you or another family member covered by your medical insurance.

• The healthcare provider and date the service was performed: Check that you recognize the doctor, hospital, or lab, and confirm that you or the family member did have service that day.
• The amount the provider billed the plan: Make sure that this is in line with the services performed on that visit. One form of medical fraud is when providers bill for more services than were provided. (Of course, there can also be clerical mistakes in billing.) If the costs seem out of line, ask the provider for an itemized statement so that you can challenge any errors.
• Breakdown of payment: The EOB will show the total cost of the service (the amount your medical insurance plan approved), your plan’s share of the cost, and what you as the patient must pay out of pocket (often the amount that has been applied meet to your plan’s deductible threshold). If charges are not covered, there will be a reason code explaining ineligible amounts or amounts paid, and there is usually a code key on the back of the statement.

What you are looking for are charges for services that didn’t happen, statements for a patient who doesn’t exist on your plan, or denial of coverage for legitimate services. Any of these can be the first signs that someone has stolen your medical identity or that of a family member. The EOB should also give a customer service number. If you see a problem, call your insurer and medical provider right away for more information to help determine the source of the problem and to challenge the charges.

(One important note: DON’T tell providers you think someone has stolen your medical identity. If you do, you could lose access to your own medical records, because the provider is required by medical privacy laws to protect that other patient’s privacy, even though they might have obtained care under false pretenses. If you think you may be a victim of medical identity theft, read this blog for information on how to proceed.)

If you make a habit of reviewing EOBs as soon as you receive them, you’ll soon be able to scan them quickly for the important information. It’s not fun but think of it as preventive self-care. Checking your EOB is like an injection of reason and caution to protect your medical coverage, and, as any good nurse will tell you, it only smarts for a second!