Last week, we introduced you to the health insurance estimation of benefits (EOB) codes. This week, we are going to help you make sense of them.
Medical care is big business in the U.S and health insurance companies are out to make money, not to make sure you get quality medical care. Keeping this fact in mind will help motivate you to be vigilant about checking to make sure you’re getting your full insurance benefits. But navigating through all those codes can be exhausting, so here are a few tips to help you get the most from your health insurance by understanding all those complex codes.
Navigating the EOB
Your health insurance company sends out an Explanation of Benefits form outlining payment information for services rendered to a person covered by your insurance plan that have been submitted for payment. This EOB form provides a wealth of information and is the first place to check for billing errors and inconsistencies.
Dates of Service
Listed on each EOB are the dates of service for charges submitted for payment. You should double check each date for accuracy and compare it against your personal calendar to ensure that you actually received services on those dates. By the way, if you’re not doing so already, you should keep a log of all medical care provided to you and your dependents. Include the date, physicians seen, services rendered, and any other details such as medications prescribed and diagnosis declared (if known).
These codes can seem intimidating at first glance, but any service code listed on the EOB is also explained, usually on the back of the EOB or in the bottom section. You should double-check your records for accuracy. For example, if your EOB service code for 11/12/2011 is a 1 (medical services), then check your records to make sure you actually received medical services on that day.
CPT Codes/ICD Codes
Since the EOB is a reflection of the information provided to the insurance company by your medical care provider, it’s also important to check up on what information your physician is recording. Doctors use sets of codes to relay information about services rendered (CPT codes and modifiers- these are listed on the RA obtained from your physician’s office if needed) and the reason the medical service was necessary (ICD codes). In order to be reimbursed for services rendered, the physician must provide a valid diagnosis to support his or her medical charges (ICD codes).
Medical coding can often be quite a creative process in some offices. Since diagnosing is a subjective process, the physician or medical billing personnel often have several related codes to choose from. Some pay less – some pay more, and ill trained personnel can be a bit erratic about their code selection. Your job as the patient isn’t to make sure your physician isn’t swindling the insurance company (and indirectly you) by embellishing his or her coding practices, but to check for errors.
To do this, you’ll need to request a copy of the physician’s billing sheet after each visit to obtain the billing codes submitted to your insurance company. There are currently two sets of ICD codes in use: ICD 9 and ICD 10. ICD 10 codes are more specific, and are being phased into use in many offices to meet the federal deadline for implementation of October 1, 2013. The way to tell which set of codes your physician is using is simple. ICD 9 Codes start with a numeral (such as 382.9 for otitis media or an ear infection), ICD 10 codes generally begin with a letter (such as H66.016 for Acute suppurative otitis media with spontaneous rupture of ear drum; recurrent, bilateral). Most offices are now using ICD 10 Codes.
You’ll need to look up the ICD code to see what diagnosis or diagnoses your doctor is providing for payment. ICD 10 codes can be found here, and ICD 9 Codes can be found here. In addition, ICD 10 code books can be purchased for personal use by consumers. ICD 9 books are no longer in print, but you can order a software version from the CDC here.
The idea is not to second-guess your doctor’s diagnosis, but to look for blatant errors. Mistakes happen. A simple transposition of a number can mean an entirely different diagnosis. Just make sure you’re not being billed for a treatment for diabetes, when you really have the flu (and have never had diabetes).
If you find an error, ask your doctor’s medical clerk or assistant about your findings. Simply explain that you are double-checking all information submitted to your health insurance company to help expedite payment and ensure accuracy, and state that you have a quick question about coding. Your dedication to fact-finding will actually benefit the physician’s office as well, since you are likely to find errors that they may have missed.