Deciphering an Explanation of Benefits

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Reading an Explanation of Benefits

• Commonalities and Differences
• Adjustment codes
• Missing EOB

Anyone who handles payments in a chiropractic office will, sooner or later, need to look at one of those confusing insurance payment explanations and decipher it. Every insurance company has their own form and style, and wordings and reasons for what they pay...or do not pay.

They even call them different things, like "Remittance Advice", "Explanation of Benefits", "Explanation of Review", "Claim Summary"... and I'm sure they'll invent more names and styles. All they are doing is tell you what they are paying and why or why not.

Here's the trick: there are only a few real things the EOB tells you:

1. Summaries: totals, subtotals, check amounts, disclaimers.
2. Identifying data: patient and doctor names and ID's,
3. Claim data: date of service, CPT codes, billed amount.
4. Reply data: payment amounts, non-payment amounts and reason codes

Most of this is easy to figure out, except the part you most want to understand: #4
Making errors in 1, 2 or 3 are a little silly, but totally possible: confusing one patient service date for another, or a summary for a payment can slow you down. After you check those, though, here's the meat.

Since everyone has to deal with Medicare, and Medicare "Remittance Advice" forms are the most complex, we'll use Medicare as the sample:


***insert more here*****

You do not have to know all the "reason codes" that payers use. Payors don't always use codes, and when they do, they always write out what those codes mean on the explanations. While Medicare dictates a list of reason codes, Medicare payors still have to write out what those codes mean on the claim form. But here what you really need to know..

THE REASONS THAT PAYORS GIVE FOR POOR PAYMENT
RARELY TELL YOU HOW TO FIX THE CLAIM.

Insurance carriers have to follow pages and pages of rules