Insurance errors
An EOB is not a bill, and it is the most useful document you have
If you have never read your Explanation of Benefits, you are fighting bills without knowing what insurance actually decided.
The Explanation of Benefits, or EOB, is the insurer's statement of what the provider charged, what the insurer allowed, what it paid, and what it says you owe. It is not a bill. The bill comes from the provider. The EOB comes from the insurer, and they are frequently different numbers.
The four numbers that matter
| Term | What it means |
|---|---|
| Billed | What the provider charged. Often far above any real market price. |
| Allowed | What the insurer agreed to pay as its negotiated price. This is the real price. |
| Paid | What the insurer actually sent. |
| Patient responsibility | What the EOB says you owe: deductible, copay, coinsurance. |
A worked example from our own case: a specialist billed $440. The insurer allowed $220.92 and paid $180.92, leaving $40 as patient responsibility. That $40 was the normal copay, paid at the visit. Once we had those numbers, the dispute was over in one call.
How to get one
Download them from your insurer's member website. You will probably need to approve a two-step code sent to your phone, which is the part a personal agent cannot do for you.
What to do with it
- Compare the bill to patient responsibility. If the bill is higher, dispute the difference in writing and ask them to bill only the EOB amount.
- Check whether the claim was processed at in-network rates.
- Look for a denial reason code you can act on.
- Save it. It is the document a regulator or an appeals reviewer will ask for.
Some insurers take days or weeks to post the EOB after the claim is processed. Ask for the expected date and set a reminder, because that date is often the difference between a quiet month and a collections notice.