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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.
There is a lot of confusing information on this document but, bear with me and I’ll walk you through it all.
OK, that’s quite a list but I’ll explain each point individually.
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.
In fact Medicare’s rates are actually as high or higher than the highest rate Blue Shield (or any other private insurance company) pays a doctor for an office visit: Incidentally, I did not negotiate with any insurance company for any of these rates, nor has any other doctor I know ever negotiated office payments with an insurance company.
Also, as far as I know, all doctors in my area get paid the same as I’m paid by the insurance companies for each billing code.
Now that I’ve shown you what an EOB looks like, let’s go over a few more.