Question

Depending on the setting that you work in, you may be required to respond to billing questions. Let's assume you are working in an office and a patient called today and asked for you to explain a form that she received from her insurance company. She said the form was called an Explanation of Benefits.

Explanation of Benefits Data

Provider: Dr. Theodore Simmons

Date: 11/11/2017

Type of Service: Office visit

Amount submitted: $82.00

Amount allowed: $74.00

Coinsurance: $14.80

Deductible: $300.00

Copay: $20.00

Application Assignment

Answer the following questions below for your patient:

1. Explain what an Explanation of Benefits form is and why it is sent to the patient.

1. Explain the difference between the amount submitted and the amount allowed.

1. Explain to the patient what the deductible is.

1. The patient believes that she was overcharged by $8.00, how do you explain her accusations?

1. The patient wants to know the difference between a copayment and coinsurance.

Answer 1

Answer:

Explanation of benefits of insurance:

By estimating the overall risk of health care and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insuranceagreement.

Difference submitted by amount submitted and amount allowed:

Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay thedifference. The health insurance orplan pays the rest of the allowed amount.

Explanation of deductible:

Deductible. The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services.

Patient's accusations that she was overcharged:

By the explanation about the difference between the amount allowed and amount submitted she will better understand that she is not overcharged.

The difference between co payment and co insurance:

Coinsurance, like a copayment, is a form of cost sharing for health services or prescription drugs between insurance companies and the insured. Unlike copays, which are flat fees, coinsurance is a percentage of the cost for a health service or prescription drug paid by a member after they have reached their deductible.