Reviewing your Explanation of Benefits (“EOB”) to Prevent Improper Charges and Health Care Fraud

July 11, 2017

When you (or a covered dependent) receive health care services from a doctor or other health care provider/facility, a claim is generally submitted on your (or your covered dependent’s) behalf to your insurance company (For the NYCDCC Welfare Fund, these companies include Empire BlueCross BlueShield, Express Scripts, and Aetna.) Once the claim is submitted and your insurance company makes a determination, based on your plan, how much to pay toward your claim, your doctor or other health provider/facility will then send you a bill charging you for the remaining amount that was not paid by your insurance company.

During this time period, you will also receive an Explanation of Benefits (“EOB”) from your insurance company, which explains the charges associated with your claim. Generally, an EOB contains the following information:

• Date of Service(s)
• Type of Service(s) Received
• Name of Doctor/Provider/Facility
• Amount Paid By Insurance Company
• What You Owe

When you receive your EOB, it is important for you to review it carefully to ensure that you actually received the services that are stated in the claim, and you are being charged the proper amount for the services listed, if in fact you did receive them. Insurance companies, as well as health care providers/facilities, can occasionally make mistakes on claim submissions, so it is always best for you to double check to be sure the charges are correct. If services are incorrect, you should report back to your insurance company and/or health care provider/facility any charges you believe are unwarranted.

Additionally, instances of health care fraud are also possible. Health care fraud is a federal crime which is deemed to have occurred when health care providers/facilities make fraudulent claims against clients for services that they never provided, submit claims using improper insurance information, or duplicate claim submissions, among other examples.

To safeguard against being improperly charged, you can protect yourself from health care fraud in the following ways:

• Ask your health care provider/facility to explain the reason for the services being provided
• Beware of “free” medical services, as illicit entities use this to obtain information from you
• Keep your insurance member ID card in a safe place
• Report instances where co-payments and/or deductibles are waived
• Do not give your insurance number to marketers or solicitors
• Never sign a blank insurance form

For more information regarding your EOBs and how to use them to protect yourself from improper charges and fraud, you can contact Empire BlueCross Blue Shield at (844) 416-6387, Express Scripts at (800) 939-2091, Aetna at (855) 201-8436, or our Member Services Department at (800) 529-FUND (3863). You can also view a video which explains EOBs by visiting the Video Library section of our website at www.nyccbf.com/news-media/videos/.