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Before I do, though, I’ll introduce you to what an explanation of benefits (EOB) is.
An EOB is a statement each insurance company sends each medical provider every time that provider bills for a service.
That means that Blue Shield has no intention of paying me the 0 I billed for that patient’s visit.
They’ll allow me to collect .69 and I can forget about the remaining .31.
The methods in which insurance companies pay doctors are varied, convoluted and rather opaque.
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Again, I billed a 99213 (same billing code as in the other examples) but this time, Blue Shield allows me to get .56, which is more than they allowed for the patient in the first example.
What’s more, that extra came out of the patient’s pocket (as a higher copay) and not Blue Shield’s. The patient in the first example had an EPO plan whereas the patient in the second example had a PPO plan. Now you’re starting to understand why most doctors have no idea how much they’re paid for an office visit.
Now, I haven’t even mentioned deductibles or co-insurances, which we bill the patient for after we see them.