An EOB usually includes:

1. Identification of service rendered*
2. Date of service (DOS)
3. Name and address of subscriber
4. Name of patient
5. Name of healthcare provider who rendered service
6. Provider’s tax identification number
7. Provider’s charge/ total billed services
8. Allowed amount
9. Total patient responsibility amount
10. Total payment made and to whom
11. The amount payable (in dollars or percentage of total) after deductibles, co-payment, and any other reduction have been made
12. An explanation of for any reason for not providing full reimbursement for the amount claimed
13. Point of contact (telephone number or address) by which an enrollee may inquire regarding payment
14. Information on the appeal process of a denial of benefits and timeline of the process

The first item, identification of service provided (marked with *) is the most important item on an EOB.  It is the reason for receiving healthcare and should be communicated via ICD (diagnosis) or CPT (procedure) codes. If you receive an EOB that is missing this, call your insurance company and ask for this information.  Keep track of the code – it represents what you received and why you received it.  Imagine that your EOB is a receipt from a store and that the ICD and CPT codes are the items you purchased.  Wouldn’t you want to know what you bought?

Unfortunately, EOBs are not standardized and can be difficult to read, especially after switching insurance providers.  In addition, an EOB is sent to both the provider and the patient, and it attempts to convey different information to each recipient.  This often produces a very confusing document.

When reading an EOB, don’t be hesitant to look for guidance.  Your insurance company may have an example EOB and accompanying information on their website.  And, of course, be sure to look at our Healthcare How To: Read an Explanation of Benefits (EOB).

Other Resources:
http://www.healthlink.com/tech_tip_eob.asp
http://www.ins.state.ny.us/website1/inshelp/c_eob.htm
http://www.cigna.com/customer_care/member/forms/explanationofbenefits.html

A recent article from the Wall Street Journal “Can Technology Cure Health Care” stated that “digital medical records come with some big promises – they’ll improve patient care, eliminate errors, stem costs and make health care more efficient.” On the other hand a 2009 study indicated that “hospitals with more-advanced electronic systems fared NO better than other hospitals on measures of admin costs, on average, even if the systems might ‘modestly improve’ performance on care.”

What does that mean? Healthcare professionals are frustrated with the electronic systems. Could it be because healthcare – notoriously slow to change – isn’t ready for the switch? Unlikely – the article surmises that it might not have to do with how the digital records are implemented, but with how they are designed.

The article discusses how hospitals can customize digital systems to fit their own unique needs. Digital technology has a chance to revolutionize healthcare. We just need to come up with a system that is uniform enough so all systems can communicate, but unique enough to satisfy each health facilities’ needs and wants.

The article highlights coding audits and the reasons for them – Rebecca asserts that in order for the Centers for Medicare and Medicaid Services (CMS) to lower its costs, it devised several financial recovery divisions to catch overpayments and fraudulent claims. Some audits include RAC (Recovery Audit Contractor), which evaluates a provider’s claims data, and medical records for possible over/under payments and ZPIC (Zone Program Integrity Contractor), which, according to the article, are the “aggressive cousins of RACs formed by CMS to detect fraudulent claims activity.”

Rebecca goes on to discuss payer fraud and how it will affect health information technology (HIM). HIM departments need to audit yearly to ensure they are not releasing personal health information (PHI) into the hands of fraudsters. As Rebecca states, “For HIM, the ‘year of the audit’ is about ‘releasers beware.’”

Criminals pose as insurers to obtain medical records and other sensitive information more times then one would think. Rebecca says, “This is what makes HIM vulnerable – people who really understand how the department works and how correspondence works. They are writing letters in a typical format that is routine. So it is going to really easy to miss letters that don’t have altruistic intent.”

With 2010 being the year of the audit everyone in the healthcare industry needs to be alert and in top form. The government is looking for overpayments. Insurance companies are looking for overpayments. Hospitals need money to continue to provide services and can’t afford to miscode, bill incorrectly or anything in between. It is a buyer’s beware market out there and patients most likely the ones to be most affected by these audit initiatives.

Frequent incidences of prescription drug misuse:
1. Doctor shopping – hopping from doctor to doctor in order to receive medication and deceive the doctor. Patients also go doctor shopping to find a doctor that will “address” all their prescription needs i.e. over prescribing.
2. Manually changing the dose of the prescription. Example: If the prescription is written for 25 pills, they might add a 1 in front of it to make it 125 or a 0 at the end to make it 250.
3. Medical identity theft – stealing a victim’s insurance card and obtaining prescriptions under the victim’s name.
4. Inside cooperation – stealing a doctor’s prescription pad and writing prescriptions.

This list is by no means exhaustive. It just gives you a clue to what is occurring.

What are Pharmaceutical companies doing?
1. Making pills tamperproof – meaning that if they’re crushed for a stronger, more rapid high they become ineffective.
2. Patient medication guides explaining the exact purpose of the drugs and the consequences of misuse.
3. Letters to doctors and additional physician training to end the misuse and inappropriate prescribing of painkillers.

Those last 2 strategies are debatable, but they are necessary steps that need to be taken to combat prescription drug addiction.

How can providers combat the misuse?
1. Electronic health records can help combat this problem. The physician would be able to see that the patient has seen an abnormal amount of doctors and see what the patient was prescribed – eliminating the ability for a patient to be over prescribed.
2. Stop over prescribing – simple as that.
3. Understand the warning signs of users.

Read the full article here.

President Obama, following former President Bush’s initiatives, is pushing for everyone to have an EHR or EMR by 2014 (EHR = Electronic Health Record, EMR = Electronic Medical Record). However the problem with this implementation is that currently, most hospitals do not have adequate safeguards to protect highly private and highly valuable medical information (medical identity information averages $50 per identity; a SSN will net thieves only $1).

In many cases, medical identity theft is committed by individuals with inside access to medical information – doctors, nurses, pharmacists, hospital workers etc. By allowing information to essentially “flow freely” throughout the healthcare marketplace we are opening ourselves up to fraudsters and thieves and making medical identity theft even easier than it was before.

According to the World Privacy Forum, 3% of all identity theft victims in the U.S. or 250,000 Americans reported that their identity had been used fraudulently to obtain medical treatment, services or supplies. The World Privacy Forum asserts that this number will only increase in the future.

While EHR adoption will push our country in the right direction in terms of quality of healthcare, what steps are we taking to prevent our most private information from being stolen and used against us?

The hacker posted on the site’s homepage an expletive filled rant claiming that he was in possession of very confidential data. He continued by writing that if Virginia didn’t follow his ransom demands, he would sell all the information to the highest bidder.

Virginia didn’t succumb to the hacker’s demands; however, their website was not functional for a period of time.

Read full article here.

This alleged breach calls into question the effectiveness and security of EHRs (Electronic Health Records). While EHRs will save an estimated $11 billion annually, skeptics say that patient information will be more vulnerable than ever.

Medical Business Associates, Inc. can consult companies and hospitals on the right way to secure online medical records. Our experts are trained to find holes and teach you the proper way to fill them. Our pre and post EHR implementation audits have saved many organizations from experiencing the headaches associated with EHR implementation.