Our team of professionals and staff believe that informed patients are better equipped to make decisions regarding their health and well-being. For your personal use, we have created an extensive patient library covering an array of educational topics, which can be found on the side of each page. Browse through these diagnoses and treatments to learn more about topics of interest to you. On this specific page we will also try to answer some of the most common questions we get from our patients regarding office visits, billing and insurances.

As always, you can contact our office with any additional questions or concerns you might have! 

One of the most frequently asked questions we receive is "Can you help me with my statement from the insurance company?"  So let's decipher these complicated statements.

EOB

How Physicians refer to your Explanation of Benefits (the statement from the insurance company regarding your doctor's visit).

Account Number

Your account number represents your number with the doctor that is assigned to you at your first visit.

Claim Number

Every claim is assigned a claim number, if you need to contact your insurance company it's helpful to have this number (will save you some time).

Date of Service

The date you saw your doctor.

Procedure Number

Here is where it gets tricky.  Every office visit is assigned a CPT code or numerical value.  Without giving everyone a billing lesson these generally run from 1 to 5 as in 99243, 99244, 99245 or 99213, 99214, 99215.  You may also see "surgical" codes here.  Whenever a physician treats you in the office whether by freezing, excising, scraping or removing, these codes fall under the "surgical" category.  

Units of Service

For example, if you had multiple Actinic Keratosis treated by liquid nitrogen you may see the first procedure number 17000 (first lesion destruction) and then you might see 17003 (4) units (second through fifth lesion destruction).  We have to code this way it's the law.

Billed Amount

The billed amount is just the amount the physician billed.  It is not the amount your coinsurance or deductible will be based on.  The doctor is required by both federal and state laws and by the contract with the insurance company to write off or adjust any amount over the "allowed amount."

Allowed Amount

This is the amount the insurance company determines the physician should charge for the procedure code.  

Contractual Adjustment Amount

This is the amount the physician must write off on primary insurance ONLY (physicians are not required to write off secondary or tertiary adjustments).

Deductible

The amount that you must pay out of pocket before the insurance company will start to pay your claims.  The physician is still required to write off the contractual adjustment even if you haven't met your deductible. 

Co-Pay

This can be the set amount you must pay at every visit and it can range from $5.00 to 75.00 or more.  This column also includes co-insurance, which represents percentage after the adjustment is made that is your responsibility.  Depending on your contract this can be 10% to 50% of the allowed charges.

Amount Paid

This is the amount that was sent to the doctor on your behalf. Also, notes at the bottom will explain why something was not allowed or why the insurance company is only paying a portion of the allowed charges and not all of them.

Additional Info

There should be a phone number on your explanation of benefits if you have any questions regarding the claim or why it was processed the way it was. Don't be afraid to contact your insurance company, sometimes an insurance company will process a claim "out of network" and the physician is "in network." If this error occurs, it will generally cost you more money.  However, insurance companies will often reprocess the claim if the original claim was processed in error.

It is also worth noting here that you choose your plan and your insurance company and your network.  The physician is not there with you guiding you during this process and that is the way it should be.  However, the physician has limited control over the terms you set with your insurance company - they are contractually prohibited from writing off co-pays or deductibles.  It is against the law for a physician to bill a procedure or office visit in a specific way only so that it may be covered by your insurance company.  They must bill for exactly what happened and when it happened.

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