What Now: How to handle a questionable charge on your Medical EOB

If you carefully review every explanation of benefits (EOB) statement from your medical insurance company, good for you! By watching for errors and unexpected charges, you’re guarding your finances and your medical identity. But what should you do if you find an unexpected charge on your EOB? Read on to find out!

(And if you don’t review EOBs, it’s time to start. Read here to learn why you should and what to look for.)

Correcting Billing Errors

The most likely cause of problems on an EOB is simple human error, such as a typo or duplicate billing. Here’s how to get billing errors corrected:

• Get your facts together. If the charge is from a medical appointment or procedure, gather copies of any receipts, diagnoses, or instructions you were given. If you don’t have paper copies, get them from your provider’s online medical portal or request copies from their office. If there are charges you don’t understand, ask you doctor’s office to explain. (For best results, ask them politely to “help you understand” this charge.)
• Request an itemized copy of the billing from your medical provider. (A medical provider is a doctor, clinic, hospital, or lab—anywhere that provides medical care.) When you receive the itemized bill, make sure to check for errors. Medical billing uses a set of standardized codes (called “Current Procedural Terminology” or CPT codes), and typos in CPT codes are a common cause of billing errors. (For example, a popular financial reporter discovered a 1-digit mistake in the CPT code that caused a simple urgent care visit to be billed as an $8,500 surgery.)
• Compare the medical provider bill against the EOB. If the provider’s bill is fine, the error was likely with the insurer.
• Dispute the charge. Once you know the source of the error, contact your medical provider and medical insurer and start their processes for disputing a claim. (You can find a sample dispute letter here.) The doctor can submit a corrected bill to your insurance or, if the mistake is at their end, write them a statement of what services you did and didn’t receive.
• Document everything. Keep notes of all conversations, including dates, names, and commitments as to next steps, etc., and keep copies of all correspondence. In serious disputes, you may need to send correspondence by certified mail with return receipts requested.

This process should resolve simple billing errors. However, surprise fees or unexpected high costs can also happen because a medical provider ordered tests or treatments that aren’t covered by your plan, or because a hospital brought in an out-of-network provider for a medical procedure. Consumer Reports offers some excellent guidance on how to dispute or renegotiate this kind of unexpected charge. Many hospitals and large health organizations also have patient advocates who can help you make your case.

If you can’t reach a resolution with your insurer, you also have the right to file an insurance appeal. Instructions for filing an appeal are included on each EOB form.

Fighting Medical Identity Theft or Fraud

If your EOB includes errors in the patient information, charges for services that never happened or for a patient who doesn’t exist on your plan, or denial of coverage, these can be the first signs of medical identity theft or fraud. These are serious because an identity thief or fraudster could run up bills that exceed your medical coverage and/or introduce life-threatening errors into your medical record.

If you think you may be a victim of medical identity theft, the most important thing is to make sure your medical record is corrected right away.

The FTC recommends these first steps:

• Request copies of your medical records from all your providers. (Do this without telling them that you suspect medical identity theft. If someone else’s medical information is in your record, they are required by law to protect that other patient’s privacy.)
• Ask each of your health plans and medical providers for a copy of the “accounting of disclosures” for your medical records. This shows what other providers may have copies of your erroneous records, so you can request corrections.
• Ask for corrections to your records, sending dispute letters just as you would for an erroneous medical charge.

While you’re getting your medical records corrected, you will also need to dispute any fraudulent medical charges using the process described above. You’ll also need to protect your medical and insurance accounts from further misuse, as outlined in this blog. Correcting medical identity theft can be a tough road, and it can pay to have expert help. If you’re an IDX Identity member, call right away so the recovery team can get to work to help set the (medical) record straight.

If you have IDX Identity or IDX Privacy, you can also use the CyberScan feature to help protect yourself against medical identity theft. Simply enter your medical insurance ID number as one of the items you want to track, and CyberScan will continuously monitor to see if your insurance information is on the dark web. If it is, you can contact your insurer about changing your ID number or other options to protect your medical identity and coverage.

Steady On

Medical billing issues can be frustrating, and medical identity theft is downright frightening. In either case, your best defense is to review EOBs and spot problems early. If you find problems, work calmly until the issues are resolved. As with so many things in life, vigilance, organization, and persistence will pay off.