Do You Understand Your Medical Insurance Explanation Of Benefits Statements?

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“We gotta go to the doctor,” my wife said as she hung up the phone.

The phone call had been from my sister-in-law, who’s family had stayed with us the previous weekend, informing us that their daughter had head lice. We piled the family into the van and quickly drove to our primary care provider, making our way into the office just a few minutes before closing.

The doctor snapped on some rubber gloves and checked us over. We breathed a sigh of relief as she stated she didn’t find anything on us. She did give us a list of things we may want to do just in case we wanted to be extra cautious.

A few weeks later we received in the mail the explanation of benefits statement from our insurance company. I expected it to tell me that our trip to the doctor was covered 100% as a diagnostic office visit.

Instead, it showed a coinsurance due of about $22 for each family member.

Phone call #1:

I called the insurance company, and a very nice lady on the other end of the phone walked me through my explanation of benefits. She showed me the code assigned to our visit, and explained that it meant that we were treated by a physician’s assistant. She went on to tell me that she may be able to help me out. As long as the assistant was working under a physician, it should be coded as a visit to our primary physician, and covered at 100%.

Side Note: I struggled with how a physician’s assistant could not be working under a physician. I mean, the title physician’s assistant sort of implies they’re working under a physician, doesn’t it?

She said she would call my primary care provider, discuss, and call me back by the end of the day. Nobody called me back.

Phone call #2:

My initial phone call was on a Friday morning, so I gave them until Monday afternoon to call back. When no call was received, I called them and was told my primary care provider simply hadn’t called them back, and they would be in touch.

Phone call #3:

The next day, my insurance company did call back just to re-iterate that they had not yet heard back from my primary care provider.

Phone call #4:

Admittedly, I got busy and forgot to follow up for awhile. A full two weeks later I called again, and was put on hold for quite a long time. When the representative came back, she informed me that they had just gotten a hold of my provider earlier that day and had successfully got the visit recoded. It would indeed be covered 100%. To be honest with you, given the amount of time I was on hold, I think they called up my provider while I was waiting.

It took four phone calls and several weeks to get it all straightened out, but I was relieved to finally have it resolved.

For years, I would just pay the medical, dental, or vision bill when it came in the mail. I wouldn’t check it over for accuracy, I’d just pay it. One would hope that they could get this correct as often as they do it, but apparently his whole coding incorrectly thing isn’t all that uncommon as I recently read a post about similar scenario over at The Money Beagle.

I wonder how many times I’d overpaid for heath care because the service was coded incorrectly.

You can bet I’ll be double checking my explanation of benefits every time from now on. I may have to call the insurance company, or I may have to call my health care provider. I may even have to call both, but I’m not overpaying anymore.

Do you check over your explanation of benefits for each medical visit? Have you ever found a mistake?

Brought to you courtesy of Brock

About the author

Brock Kernin


  • Being in health care I can tell you that even most of us don’t understand all the changes that are going on. You should always check and question everything. There is so much that is changing that you really have to be vigilant. It is more complicated for patients and for providers than ever.

  • I hardly ever pay a visit to a doctor, so so far I never bothered to check closely my benefit statements. Nevertheless, I’m kind of wondering on which end they messed it up… I recently just read an article about how different people got different bills for the same treatment… It reminds us to recheck everything to make sure that we get what we pay for.

  • @MoneyBeagle – I’m shocked at how often it happens…after telling some of my friends about our experience, some shared similar experiences while others kind of looked at us with that “deer in the headlights” look….wondering how many times they’ve overpaid as well! I fought once unsuccessfully as well…it never hurts to try, right?

  • @Kayla – good job! Of course it doesn’t just apply to medical bills, we need to make sure we check *all* our bills – cable, garbage, utility, etc, etc. Check ’em all! Thanks for your comment!

  • @poorstudent – I’ve read similar stories – it shouldn’t be that hard to be consistent with how things are billed…but I guess human error can pop up at anytime. Check, double check, and triple check those bills and don’t pay ONE CENT more than you really should owe! Great to hear from you!

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