Understanding Medical Billing

Below is a list of medical billing frequently asked questions.  If you have any additional questions, please contact a Financial Counselor today at (937) 547-5770.

 

Medical Billing Frequently Asked Questions

Adjustment - A charge that relates to how a claim is paid differently from the original billing

Amount not Covered - The amount of services/products not covered by the plan

Charges - Amount billed

COB - Coordination of benefits is the practice of ensuring that insurance claims are not paid multiple times when an enrollee is covered by two health plans at the same time

Coinsurance - What the patient must pay the health plan after the health plan pays the covered percentage

Copay - The amount the patient pays the provider for a visit/service

Dates of Service - When the patient received services

Deductible - The amount the patient pays toward covered services each year before the third party payer starts paying for services

EOB - EOB is an explanation of benefits document issued by the payer stating the status of the claim; whether it is paid, suspended (pending), rejected or denied

FAP - Financial Assistance Program

HCAP - Hospital Charity Assistance Program

In-Network & Out of Network - In-network refers to a provider or health care facility that is contracted and is part of your health insurance's network of providers and facilities. Out of network means that the doctor or facility providing your care does not have a contract with your health insurance company. Note: Health insurance companies prefer you to seek care from their in-network providers because it costs them less. If you choose to see an out-of-network provider, it will cost you more.

Patient Responsibility - What the patient must pay of the billed charges after the plan benefits have paid

Percentage % - Percentage level of benefits for covered services/products

Service/Product Description - Services the patient received from the provider

Total Amount Eligible for Benefits - Charges billed by the provider minus the provider fee adjustment minus patient copay, deductible, or amount not covered

Total Paid by Health Plan - Total amount eligible for benefits minus coinsurance amount