; Report Healthcare Fraud – Preventing Healthcare Fraud | BCBS.com
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Explanation of Benefits

Health insurers send an Explanation of Benefits, or EOB, to their covered members after they or other family members receive healthcare services.  The EOB is one way that insurer’s can help patients manage their healthcare, and a way for patients to help their insurer verify services and control costs.

Patients should carefully read and review the EOB because it provides a list of services that the medical provider or supplier claims to have provided to the patient.  Simple errors can often be corrected by contacting the provider and/or health insurer's customer service department. However, if the EOB contains inaccuracies or discrepancies that cause a patient to question whether an honest claim for payment has been submitted, patients should contact their health insurer’s anti-fraud department to report this information.

Pictured below is a SAMPLE EOB.  This is not an actual EOB and may be different from the one you receive from your insurer. 

To access your own EOB, please log in to your local Blue Cross and Blue Shield Company website.

To view possible health care fraud scenarios, please mouse-over the numbers and view the explanation.

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.