Interactive Explanation of Benefits (EOB)
It is important to carefully read the Explanation of Benefits, or EOB, when you receive it. Your health insurer sends this document to you after you or a covered family member receives healthcare services.
Reviewing your EOB is a big step in preventing healthcare fraud and medical identity theft. If you find inaccuracies in this form, you should contact the medical provider and your health insurer's customer service.
Here is a key to some of the parts of the sample EOB that is pictured here. This is ONLY A SAMPLE REPRESENTATION and is NOT an actual EOB. The one you receive from your insurer may be different.
To view how fraud can occur in your EOB, please mouse-over the numbers to view explanations.
1
Incorrect name/address may indicate that you have been a victim of ID theft; unapproved use of your medical identity, or that a clerical mistake has caused you to receive another person's EOB. Contact your insurer if you find that this information is incorrect.
2,3,4
Incorrect group or identity number may indicate that you have been a victim of ID theft; unapproved use of your medical identity, or that a clerical mistake has caused you to receive another person's EOB. Contact your insurer if you find that this information is incorrect.
5
The person who received the indicated services—deliberate errors in this field may indicate that someone is trying to obtain additional payment. Or it could indicate that someone else received services which are being billed to your ID number. This may indicate ID theft or other fraud. Incorrect information could result in a false diagnosis on your medical record creating a dangerous situation for you or a covered family member.
6
Summary box, including the total billed by the provider for the services, shows the benefits approved and paid by your health insurer. You may owe the remainder. If these amounts are well above what you were led to believe, this may indicate your bill is being inflated to increase payment beyond what was authorized. Report this to your insurer.
7,8
Check descriptions and dates of services. Wrong information may indicate that services are being misrepresented to receive higher payment than authorized. Please contact your insurer if you find errors in this field.
9
Amount billed by the provider for each service. If these amounts are well above what you were led to believe, this may indicate your bill is being inflated to increase payment beyond what was authorized. Report this to your insurer. (See #10)
10
Amount you may be responsible for paying. If services and costs are beyond expectations then you may have paid too much. Contact your insurer to determine if you are due a refund from your provider.
