My patient purchased a hearing aid with a stated insurance benefit but the EOB is only half the amount and the insurance company says the patient does not have to balance-pay.
Does the insurance EOB (Explanation of Benefits) supersede a contract with me and the patient about being billed for any balance the insurance company does not cover.
Does the insurance EOB supersede a contract with me and the patient about being billed for any balance the insurance company does not cover.
I would closely examine the contract with the insurance company but I understand the contract is exactly that – a contract between the provider and the insurance company to pay an agreed upon amount for certain services. This should be reflected in the insurance company fee schedule. Unless they have some wording in the contract that allows the EOB to supercede the contract – I would question the insurance company on the EOB amounts and ask them why it differs from what is in the contract.
It may be a situation where they just paid less hoping nobody would notice or question the amount. You would be surprised how few question the amount paid on an EOB versus the contracted amount. Many providers may not even remember on know what the contracted amount is.
Thanks for your question.