Learning About Your Medical Bill

What is a medical bill?

A medical bill is a statement that shows how much you owe your health care provider for services you received.

When will you have to pay your bill?

When you pay your bill depends on whether you have health insurance.

If you don't have health insurance, you may have to pay your bill on the same day you get care. Or your provider may send the bill straight to you to be paid in full.

If you have health insurance, your provider may send the bill (called a claim) to your insurance company first. The claim lists the services you received. It also says how much they cost. Your health care provider will find out which services your insurance plan covers. Then you will get a bill that shows you how much you need to pay.

You may get a statement from your insurer before you get a bill from your provider. This statement is called an "Explanation of Benefits" (EOB). An EOB is not a bill. It shows how much your insurance paid your provider for covered services. And it shows the amount you may have to pay for services that your plan does not cover.

What if you get a bill before your insurance pays your provider?

Sometimes you may get a bill before your insurance has paid your provider. And you may get a bill from each provider that gave you care. For instance, if you had surgery, you might get a bill from the surgeon and the hospital.

Before you pay any bills, check with your insurance company. Find out if they already paid your provider for any services. If they did, your bills may show more than you need to pay. Your insurance may be paying for some or all of the bills.

What do you need to know about your bill?

Your bill and EOB will give you a lot of details. In general:

• Your bill from your provider shows the charges for services you had. It may show which charges were paid by your insurance. And it shows the total amount you owe.

• Your EOB from your insurer lists:

  • The services you had.

  • The amount your insurance paid your provider for each service.

  • The amount your provider will bill you for.

It may be hard to understand your bill and EOB. Read them closely. If you have questions about parts of your bill, call your provider. If you have questions about your EOB, call your insurance company.

These are some common terms used in these statements.

Personal and employer terms:

• Member or subscriber: This is the person who pays for the plan.

• Group and group number: This is the name and ID number of your employer. (You will see this if you get your plan through work.)

Provider and medical services terms:

• Provider: This is the name of the health care provider or facility (such as a hospital or lab) that provided your care.

• Service date: This is the date when you had your care.

• Service description: This describes the medical services you had.

• Charges: This is the amount your provider charged for the services you had.

Benefits terms:

• Amount paid: On your EOB, this is the amount your insurer paid your provider. On your bill, this is the amount you or your insurer paid your provider.

• Network savings, contractual adjustments, or negotiable savings: This is the amount you saved by using a provider who contracts with your insurer.

• Out-of-network: These are health care services received outside of a plan's network of providers. Services that you get out-of-network often cost more than services you get in-network.

• Out-of-pocket expenses: These are health care costs you have to pay with your own money.

• Exclusions, limitations, or noncovered: These are services that aren't covered by your plan.

• Other insurance: This shows the amount your other insurance paid for these services.

• Denial of claim: Sometimes a plan refuses to pay for a certain health care service.

Payment terms:

• Deductible: This is the amount you have to pay each year before your plan starts to pay for your care. Your EOB may show you how much you have paid toward your deductible.

• Co-pay: This is a set fee you pay each time you get certain types of care.

• Coinsurance: This is the amount you have to pay after you meet your deductible.

• Account balance: This is the amount you owe.

Can you set up a payment plan to pay your bill?

Most doctor's offices and hospitals will let you set up a payment plan. You pay the same amount each week or month until your bill is paid in full. Check with your provider to find out how the payments work.

If you can't pay your bill at all, talk to your provider to see if you qualify for any financial assistance programs.

What can you do if there's a mistake on your bill?

Mistakes can happen. So be sure to read your bill and EOB closely before you pay anything. If you have any questions about a charge or service on your bill, call your provider's office or insurance company.

When you review your bill and EOB, check to be sure that:

• The name of your provider or the facility where you received your medical care is right.

• The date of service is right.

• The type of procedure or service you received is right.

Current as of: August 6, 2023

Content Version: 14.0

Care instructions adapted under license by your healthcare professional. If you have questions about a medical condition or this instruction, always ask your healthcare professional. Healthwise, Incorporated disclaims any warranty or liability for your use of this information.