Steering clear of unexpected medical costs: Understanding billing and EOBs

Steering clear of unexpected medical costs: Understanding billing and EOBs

June 5, 2019
a couple reviews their medical billsDepending on the services you get, even a simple visit to the doctor's office may end with more than one bill or explanation of benefits (EOB). This may surprise you if you don’t know how providers bill.

Most providers bill separately

Take your annual check-up (a covered preventive service). You go to your primary care provider (PCP). While you’re there, your PCP orders lab work. You confirm the lab is in-network and bring your order to a lab across the hall from your PCP’s office. Your annual check-up has just led to two different procedures.  During your check-up, your PCP also refers you to an allergist. Once the referral is authorized, you make an appointment and go. 

Tips for managing medical costs

When booking your appointment (and during your visit), ask your primary care provider (PCP) if services or tests are preventive or diagnostic in nature. Certain preventive screenings are covered at 100% when you go to an in-network provider and the provider bills them as preventive. If you do not use an in-network provider or if your provider does not bill the service as preventive, you may be responsible for a share of the cost.

Talk to your PCP about the need for tests or referrals to a specialist. Don’t be afraid to ask questions about who you may get a bill from, whether that provider is in the network and whether the tests will be considered preventive. A BCBSTX Personal Health Assistant (PHA) can help estimate your expected cost before you have services.

Before you visit a lab, diagnostic clinic and imaging center, be sure it’s in-network. If it’s not, ask your PCP to refer you to one that is in the network.

Review your plan benefits before you get care. Your plan’s Master Benefit Plan Document on the Publications and Forms page of the HealthSelect website is a comprehensive resource on what services your plan covers and excludes, how your plan works and your share of the costs for services covered by the plan.

Visit https://www.ers.texas.gov/Avoiding-Unexpected-Health-Costs for more tips.
If you are enrolled in HealthSelect of Texas®, Consumer Directed HealthSelect SM or HealthSelect of Texas Out-of-State, each provider who performs a service will file a claim with Blue Cross and Blue Shield of Texas (BCBSTX)—whether they are across the hall or in a different location; BCBSTX will process each claim and create an EOB for you. As a result, you may get three EOBs: one for the annual check-up with your PCP, one for the lab work and one for the specialist. You may also get an EOB from the provider who read and provided the results of any screenings or imaging done to help the allergist make a diagnosis. You may also get separate bills from the different providers. (Remember—an EOB is not a bill. Your providers will bill you directly for any amounts you may owe them.)

Checklist for reading your EOB

It’s important to look at the EOBs you get from BCBSTX to ensure they show the actual services you got and the providers you saw. Check the bills you get from providers to verify that the amount you are billed is correct.

For every EOB you get, you should check that the following information is right:
  • the dates of service,
  • the person listed as the patient for that services,
  • the provider and
  • the services provided.
While you’re getting care, it never hurts to ask what a provider is doing and why. And your provider should answer in a way you understand. It’s your right as a patient to know about services and care you’re getting. Not only will it make it easier to understand your EOB and any bills you might get, strong communication with the provider could lead to better care.

Whether it’s routine care, a surgery or procedure, it’s best to approach your health care with an understanding of the road ahead.

If you have questions about your EOBs, call BCBSTX toll-free at (800) 252-8039 and a BCBSTX Personal Health Assistant (PHA) can help. If you think a provider is billing you or your insurance for care you didn’t get or didn’t need, call the Fraud Hotline toll-free at (800) 543-0867 or complete an online report.

HMOs

Community First Health Plan (CFHP)

Those enrolled in Community First Health Plan (CFHP) can logon to  www.members.cfhp.com and click on member login to access the online member portal.
 
  1. Enter your username and password or register for an account.
  2. Once in the portal, click on "My Claims."
  3. View or print your explanation of benefits (EOB).
If you need assistance, please call Member Services directly at (210) 358-6262 (TTY: (210) 358-6080), Monday - Friday, 8:30 a.m. - 5 p.m. CT to request that a copy of an EOB be mailed to you.

KelseyCare powered by Community Health Choice

Those enrolled in KelseyCare powered by Community Health Choice  can go to the plan website.

Participants can also call  toll-free at (844) 515-4877 or, local,  (713) 295-6792 (TTY:771), Monday - Friday, 8 a.m. - 5 p.m. CT.

Scott and White Health Plan

 Scott and White Health Plan members  have to manually opt-in to get EOBs in paper, otherwise electronic is the default option.

To access your EOB, go to ers.swhp.org, click “Log In” and enter your user name and password.  Then:
  1. Click “Claims” from the menu on the left. 
  2. On the Claims page, select the name of the participant you want to view claims for, from the dropdown menu. 
  3. In the “Claim No.” column of the claims display, click on the blue highlighted claim number to see your EOB (EOBs are added on a monthly basis). If your EOB is not yet available, click on the blue highlighted claims amount in the “Paid by Plan” column to see a quick snapshot of your claim and other details of service. 
Members can also call Scott and White tollfree at  (800) 321-7947 (TTY: (800) 735-2989), 24 hours a day / 7 days a week .