Can you explain my bill?
wellbody attempts to explain the EOB from insurance companies
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John Smith 1/01/1980 Date of Service: 3/03/2008 wellbody, Dr. Goldstein
CPT Charge Allowable Discount Copay Deductible Co-Ins Total Pd Owed by Patient
99213 100.00 75.00 25.00 20.00 55.00 0.00 0.00 55.00
87780 25.00 18.00 7.00 0.00 0.00 0.00 18.00 0.00
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ICD-9 Code: 462 18.00 55.00
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What is CPT and ICD-9
CPT is a number given to every procedure done in the medical office. There is a code for the visit, a code for any
immunization given, any lab drawn, any surgery such as a wart removal, and any test such as a strep test. In the above
example the 99213 is a visit and exam by the doctor for John Smith. The second code, 87780, is a rapid strep test done
for a sore throat.
ICD-9 is a number given to every diagnosis made in the medical office. There is a code for every diagnosis such as sore throat
(as in the above example- 462), back pain, or high blood pressure.
How is the Charge decided? The charge is decided by the doctor.
The charge is created by the doctor's office. Each code has a different charge. In this example the 99213 is $100.00 and a
rapid strep test is $25.00. Each CPT code can be a different charge in every doctor's office thus a 99213 may be $100.00 at
wellbody and $200.00 at the doctor's office down the street.
How is the Allowable Charge decided? The allowable charge is decided by the insurance company.
Each insurance company requires every participating doctor's office to sign a contract. Here are some rules signed by the
physician and the insurance company:
1. The doctor makes each CPT code whatever charge he decides. A 99213 can be $100.00 or $1000.00.
2. The insurance company will decide what is allowed by the contract. Thus this example shows a 99213 is allowed $75.00
Another insurance company may allow $50.00 or $90.00 depending on their contract with the doctor.
3. The doctor agrees NOT to bill the patient any remaining discount- in this example $25.00 is 'written off'.
4. If the contract does not allow the CPT code- the doctor can charge the patient the full amount, in this case $100.00 (or the
doctor can write off part of the bill with the patient as long as there is no contract (between the doctor and the insurance
company).
What happens to the discount? The Discount is decided by the insurance company.
The discount, as agreed by the contract between the insurance company and the doctor, the discount is "written off". The
patient is not responsible to pay the discount. It is the decision of the doctor to "write off" some amount of his charge for the
ability to be "in network" with a certain company. If the doctor is "out of network" (has not signed a contract with the insurance
company) - the patient will be expected to pay the entire charge as there is no contract between the insurance company and the
doctor, and thus the insurance company will not "allow or discount" any charges.
What is the copay? The copay is decided by the insurance company.
The co-pay is the amount to be paid at the time of the visit. Unless there is not a co-pay in the contract between the patient and
the insurance company, it MUST be paid at the time of service in every situation. In fact, in the contract between the doctor and
the insurance company, it states that the doctor is fraudulent if he collects co-pays from one insurance company's patients, such
as Cigna, and not another's company, such as Blue Cross. The doctor can actually get in trouble for not collecting your co-pay.
What is the deductible? The deductible amount is decided by the patient and the insurance company.
This is part of the contract between the client and the insurance company. It states the amount the patient will pay before the
insurance company begins to pay. It might be $1000, or it could be $10,000.00. The higher the deductible, the lower the
monthly payments to the insurance company. But the deductible, by law, must be paid to the doctor in the amount allowed by
the insurance company. Deductibles that remain unpaid are subject to collection agencies, injury to the patient's credit report, and
even a law suit against the patient.
When signing your contract with the insurance company, keep in mind that you can adjust the deductible- the higher the
deductible the more attractive the monthly health insurance costs appear- but the more you will owe when you visit the doctor.
The more you pay in health care costs each month, the less you will see bills from your individual doctors. Remember, the
insurance company, in many instances, has already discounted the charges from the doctor (per the contract between the doctor
and the insurance company), but the patient remains responsible to pay the remainder of the charges (as agreed per the contract
between the patient and the insurance company).
What is co-insurance? The co-insurance % is decided by the patient and the insurance company.
Co-insurance is not a part of every patient's contract with the insurance company. If it is a part of your contract it describes a
percentage of certain allowable charges that must be paid by the patient. An example would be a 20% co-insurance for visits
pertaining to urgent care visits. If you visit the doctor for a health visit for immunizations the co-insurance does not impact your
balance- but if you go to the doctor and get a throat culture- you will owe 20% of the allowable bill. The co-insurance portion of
the contract has several different equations, check yours!
Explain Total Pd and Total owed by Patient:
Total pd is what the insurance company paid the doctor. The Total owed by Patient is what the patient owes the doctor
according to the contract the patient agreed to between the patient and insurance company.
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wellbody will be happy to help you with your Explanation of Benefits by calling 913-469-1225 and asking
to speak with the Finance Manager.