An Explanation of Benefits (EOB) is a document sent by an insurance provider to an enrollee and the enrollee’s healthcare provider.  An EOB is produced in response to a claim for healthcare service.  It contains important information regarding the payment responsibilities of both the insurance company and the patient.  Unless they cover the entire cost, an insurance company is required to send an EOB to both the patient and the provider.

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

The Virginia Prescription Monitoring Program website was breached in late April by a hacker demanding $10 million in return for the confidential medical information of 8.3 million patients.

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.