Reading an explanation of benefits without losing an afternoon

An explanation of benefits is not a bill. It is the arithmetic behind one, and it arrives before the bill often enough to cause genuine alarm. Almost every line on it is explained by six terms.

The six terms

Work through these in order and the statement usually resolves:

• Billed amount: what the provider asked for. Rarely what anyone pays.
• Allowed amount: the contracted rate your insurer has negotiated. The difference is usually written off in network.
• Deductible: what you pay before the plan starts contributing. Applied to the allowed amount, not the billed amount.
• Copay: a flat fee for a defined service, collected at the visit.
• Coinsurance: your percentage share after the deductible is satisfied.
• Out-of-pocket maximum: the annual ceiling. After it, covered in-network services are paid in full.

Where out-of-network changes things

Out of network, there is often no contracted allowed amount, so the write-off disappears and the gap between billed and allowed can fall to you. This is the single most common source of a surprise number.

Aurelia is a direct-pay practice, which means membership is billed to you rather than to a plan. We generate an itemised superbill after every visit so you can claim out-of-network reimbursement if your plan offers it. Whether it reimburses, and how much, is between you and your insurer.

What we do on your behalf

Our care coordinator files prior authorisations for imaging and specialty medication, which typically take three to ten business days depending on the plan. We also appeal denials where there is a clinical case, and we will read an EOB with you at any visit.

Laboratory work, imaging and specialist care that we refer you to are billed to your plan in the normal way, so the usual network rules apply to those.

This is general information about how health plans work in the United States, not financial or legal advice, and every plan differs. Check your own plan documents.