2 Your Health: Medicare and Me

Leah Kari, certified medical representative and licensed insurance agent specializing in Medicare products

You as a Medicare beneficiary regularly receive a thick, ominous appearing envelope mailed by the Centers for Medicare and Medicaid. It’s your Medicare “explanation of benefits” or EOB. If you are on original Medicare, it’s called a Medicare Summary Notice. Your Medicare Advantage plan sends out its own EOB.

Although the first page always reassures us that “this is not a bill,” but scanning the document can quickly raise anxiety. The tendency is to interpret it as a bill, and a complicated one. As a Medicare products specialist and licensed insurance broker, I am often asked to decipher someone’s EOB, and I always learn something.

Your EOB is a good thing. It’s a record of your care, the costs, and what’s been approved, denied, and paid by Medicare. It can help you prepare your taxes, budget for healthcare, and guide your selection for future care. Your EOB explains an increase in prescription drug costs, marking your progression into the coverage gap or “donut hole.” You’ll also see if you have satisfied any deductibles of your plan.

Your EOB lists the service received, the service code and date of care. EOBs can jolt you as you see the “charge amount” or the amount your provider has billed Medicare as the fee he or she deems appropriate for the service. Contrasted with the “allowed amount,” the amount Medicare approved, the difference may appear considerable. Medicare’s share of the “allowed amount” is 80%, and is the next entry on the EOB. You’ll see the amount you may be billed, and it reflects any unpaid deductible, coinsurances, and costs of treatments Medicare did not approve. The footnotes explain why a service was denied or clarify adjustments in the amount you may be billed.

Your EOB should be reviewed promptly. It’s a ready reference should you have a payment dispute, where a provider may not have recorded your payment. Your EOB is proof of payment to resolve the matter.

Your EOB may save Medicare money. Checking your EOB may reduce costly waste and abuse of the Medicare system, as well as outright fraudulent activity. One of my clients presented her EOB to her provider that listed a surgical procedure, billed to Medicare, when no such procedure took place. This saves Medicare dollars which benefits us all.

Your EOB can be digital. Visit https://www.MyMedicare.gov and register for an account. You’ll have a record of your claims, provided you are on original Medicare. If you’re on an HMO or PPO, your “My Medicare” account will direct you to your Medicare Advantage plan for claims information. Your EOB can be accessed online by registering for your insurance plan’s personal account.

Digital EOBs make record keeping simple, but if you prefer a paper document, store this in a binder or file. If you keep it in the original envelope, mark the month and year in large letters to make easy work of finding the correct EOB. While the EOB is a daunting document, do remember, “this is not a bill.”

Leah Sugar Kari, Certified Medical Representative, and retired pharmaceutical representative, is a local, licensed life and health insurance broker specializing in showing Medicare eligible people their insurance options in Tucson. You can reach Leah for comments at 520-484-3807 or email [email protected] (TTY users dial 711.)