Patients

Understanding Your Medical Bill

Medical bills can be confusing. This guide explains the most common line items and what they mean so you can review your bill with confidence.

What is a medical bill?

A medical bill is a statement from your provider or facility listing the services you received and the charges associated with them. It is separate from your Explanation of Benefits (EOB), which comes from your insurance company.

Common line items explained

Office visit charges cover the provider's time and evaluation. Procedure codes identify specific services performed. Facility fees may appear separately if care was provided in a hospital or outpatient center. Lab and imaging charges are often billed by a separate entity.

Patient responsibility

Your patient responsibility is the amount you owe after insurance has paid its portion. This includes your deductible (the amount you pay before insurance begins), your copay (a fixed amount per visit), and coinsurance (your percentage share after the deductible is met).

What to do if something looks wrong

Contact your provider's billing office directly. Ask for an itemized bill that lists each service individually. Compare it to your EOB from your insurance company. If you believe a charge is incorrect, you have the right to request a review.

Payment plans and financial assistance

Most practices offer payment plans for patients who cannot pay in full. Ask the billing office about your options. Many providers also have financial assistance programs for patients who qualify based on income.

Protect your privacy: Please contact your medical practice directly about a specific bill or claim. Do not send medical details through this public page.

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Patients

EOB vs. Medical Bill

Two documents arrive after a medical visit — and they are not the same thing. Understanding the difference helps you know what you owe and why.

What is an Explanation of Benefits (EOB)?

An EOB is a document from your insurance company — not a bill. It explains how your insurer processed a claim: what was billed, what was allowed, what the insurer paid, and what portion is your responsibility. An EOB is for your records.

What is a medical bill?

A medical bill is a request for payment from your provider or facility. It reflects the amount you owe after insurance has processed the claim. You should not pay a bill until you have received and reviewed the corresponding EOB.

Why they may show different amounts

Insurance companies negotiate contracted rates with providers. The billed amount on your EOB may be higher than the allowed amount. The difference is typically written off by the provider. Your bill should reflect only your share of the allowed amount.

What to do if they do not match

If your bill is higher than the patient responsibility shown on your EOB, contact your provider's billing office. Bring both documents to the conversation. Discrepancies are often the result of a billing error or a timing issue with insurance processing.

Protect your privacy: Please contact your medical practice directly about a specific bill or claim. Do not send medical details through this public page.

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Patients

Insurance Terms in Plain Language

Insurance language can feel like a foreign language. Here are the most common terms explained simply.

Deductible

The amount you pay out of pocket each year before your insurance begins covering costs. For example, if your deductible is $1,500, you pay the first $1,500 of covered services yourself. After that, your insurance begins to share costs.

Copay

A fixed amount you pay for a covered service, usually at the time of the visit. Copays are typically set by your plan and do not count toward your deductible.

Coinsurance

Your share of costs after your deductible has been met, expressed as a percentage. If your coinsurance is 20%, you pay 20% of covered costs and your insurer pays 80%.

Out-of-pocket maximum

The most you will pay in a plan year for covered services. Once you reach this limit, your insurance pays 100% of covered costs for the rest of the year.

In-network vs. out-of-network

In-network providers have a contract with your insurance company and have agreed to negotiated rates. Out-of-network providers have not, which typically means higher costs for you.

Prior authorization

Approval from your insurance company required before certain services, procedures or medications are covered. Without it, your insurer may deny the claim.

Claim

A request for payment submitted to your insurance company by your provider after you receive care.

Protect your privacy: Please contact your medical practice directly about a specific bill or claim. Do not send medical details through this public page.

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Patients

Prior Authorizations: What Patients Should Know

Prior authorization is one of the most common sources of delay and confusion in healthcare. Here is what it means and what you can do.

What is prior authorization?

Prior authorization (also called pre-authorization or pre-approval) is a requirement from your insurance company that your provider obtain approval before certain services, procedures, medications or referrals will be covered.

Why does it exist?

Insurers use prior authorization to review whether a service is medically necessary according to their criteria before agreeing to pay for it. The process is managed between your provider and your insurer — but it directly affects your care and your costs.

What happens if authorization is not obtained?

If your provider performs a service that required prior authorization and did not obtain it, your insurer may deny the claim. You could be responsible for the full cost. Always confirm with your provider's office that authorization has been obtained before scheduled procedures.

What you can do

Ask your provider's office whether the planned service requires prior authorization. Ask them to confirm it has been approved before your appointment. If a claim is denied due to lack of authorization, ask your provider whether an appeal is possible.

Protect your privacy: Please contact your medical practice directly about a specific bill or claim. Do not send medical details through this public page.

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Medical Offices

Insurance Verification Checklist

Verifying insurance before the patient arrives is one of the most effective ways to prevent claim denials and billing delays. Use this checklist to confirm coverage at each visit.

Patient and policy information

Confirm the patient's full legal name, date of birth, and insurance ID number. Verify the policyholder's name and relationship to the patient. Confirm the group number and plan name.

Coverage and eligibility

Confirm the policy is active and the effective date. Verify the plan type (HMO, PPO, EPO, POS). Confirm whether the patient has met their deductible and what the remaining balance is. Note the out-of-pocket maximum and current balance.

Benefits for the planned service

Confirm the specific service or procedure is a covered benefit. Note the copay or coinsurance amount for the visit type. Confirm whether a referral is required. Confirm whether prior authorization is required and obtain it before the visit.

Network status

Confirm the provider is in-network for this patient's plan. If the provider is out-of-network, inform the patient of the cost difference before the visit.

Documentation

Record the name of the representative you spoke with, the date and time of verification, and the reference number if provided. Keep this documentation in the patient's account.

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Medical Offices

Denial-Prevention Checklist

Most claim denials are preventable. This checklist covers the most common reasons claims are rejected before or after submission.

Before the visit

Verify insurance eligibility and benefits. Confirm prior authorization is in place for services that require it. Confirm the referral is on file if required by the plan. Verify the provider is in-network for the patient's plan.

At the time of service

Collect the correct copay or patient responsibility amount. Confirm the patient's demographic information is accurate and matches the insurance record. Obtain updated insurance cards and photo ID.

Before claim submission

Confirm the diagnosis codes support the services billed. Confirm the procedure codes are accurate and complete. Verify the rendering provider's NPI is correct. Confirm the place of service code is accurate. Review the claim for missing or incomplete fields.

After submission

Monitor claim status within 7–10 business days of submission. Address rejections promptly — most have a short correction window. Document all follow-up activity in the patient account.

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Medical Offices

Authorization Tracking Guide

Authorizations that expire unnoticed or run out of approved visits are a common and preventable source of claim denials. This guide outlines a practical tracking process.

What to track for each authorization

Record the authorization number, the payer that issued it, the approved service or procedure, the date range it covers, the number of approved visits or units, and the provider it is tied to.

Setting up a tracking system

Use a shared spreadsheet or your practice management system to log all active authorizations. Sort by expiration date so upcoming expirations are visible. Assign a staff member to review the list weekly.

Renewal triggers

Set a reminder to begin the renewal process at least two weeks before expiration. For authorizations tied to visit counts, flag when 75% of approved visits have been used. Do not schedule visits beyond the authorization window without confirming renewal.

When an authorization is denied or delayed

Document the denial reason and date. Contact the payer to understand the specific requirement that was not met. Submit a peer-to-peer review request if the denial is based on medical necessity. Inform the patient of any delay before their scheduled appointment.

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Medical Offices

Month-End Billing Review

A consistent month-end review helps leadership understand the financial health of the practice and catch problems before they compound.

Charges and collections

Review total charges for the month. Compare collections to charges to calculate your collection rate. Compare both figures to the same period in prior months to identify trends.

Accounts receivable aging

Review the A/R aging report by payer and by age bucket (0–30, 31–60, 61–90, 90+ days). Identify payers with a high volume of claims in the 60+ day bucket. Flag any claims approaching timely filing limits.

Denial review

Review the total number and dollar value of denials for the month. Identify the most common denial reasons. Determine whether denials are concentrated with a specific payer, provider or service type.

Outstanding authorizations and follow-up

Confirm all pending authorizations have been followed up. Review any claims on hold waiting for additional information. Confirm patient statements have been sent for outstanding balances.

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Medical Offices

Clean-Claim Checklist

A clean claim is one that is accepted and processed by the payer on first submission without requiring additional information or correction. Use this checklist before submitting.

Patient and insurance information

Patient name matches the insurance record exactly. Date of birth is correct. Insurance ID and group number are current. The correct payer ID is used for electronic submission.

Provider information

Rendering provider NPI is correct and active. Billing provider NPI and tax ID are correct. Place of service code matches where care was delivered. Referring provider NPI is included when required.

Diagnosis and procedure codes

ICD-10 codes are current and specific to the level of detail documented. CPT or HCPCS codes accurately reflect the services performed. Modifiers are included where required and are appropriate. Diagnosis codes support the medical necessity of the services billed.

Authorization and referral

Authorization number is included on the claim when required. Referral information is included when required by the plan. The authorization covers the date of service and the specific service billed.

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Medical Offices

EHR and Workflow Readiness

Billing problems often originate in the clinical workflow before a claim is ever submitted. This guide helps identify gaps in your current process.

Documentation and coding

Are providers documenting at the level of specificity required to support the codes being billed? Are diagnosis codes being selected from a current ICD-10 list? Is there a process for reviewing documentation before claims are submitted?

Front-desk and intake process

Is insurance verified before every visit? Is the patient's demographic information reviewed and updated at each visit? Are copays and patient balances collected at the time of service?

Authorization and referral management

Is there a defined process for identifying services that require prior authorization? Is there a tracking system for active authorizations and their expiration dates? Are referrals confirmed before the patient is scheduled?

Claim submission and follow-up

How quickly are claims submitted after the date of service? Is there a defined process for following up on unpaid claims? Are denials reviewed and worked within a defined timeframe?

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Prospective Clients

Services Overview

Fate MBS provides billing and practice support built around the problems your practice is actually facing. Here is a summary of what we offer.

Billing and payments

Charge and claim review, claims submission, payment posting, ERA processing, patient billing support, claim-status follow-up, payment reconciliation, monthly billing reports and custom reporting.

Recovery and risk

Denial management, appeals, aged accounts receivable recovery, old A/R review, underpayment identification, billing audits, coding and documentation review, compliance support and Alaska Medicaid self-audit support when applicable.

Payer access

Eligibility verification, prior-authorization support, referral tracking, provider credentialing coordination, payer enrollment, ERA and EFT enrollment, payer contracting and contract and reimbursement review.

Practice operations

New-practice billing consultation, revenue-cycle workflow design, staff training, provider onboarding, billing research, reporting development, authorization tracking processes and customized administrative support.

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Prospective Clients

Is Billing Support the Right Fit?

Outside billing support is not the right answer for every practice. Here are signs it may be worth a conversation.

Signs your billing process needs attention

Claims are sitting unpaid for more than 45 days without follow-up. Denials are recurring for the same reason without a root-cause fix. Your A/R is growing month over month. Staff are spending significant time on billing tasks that are not getting resolved.

Signs your team lacks visibility

Leadership cannot easily answer what has been billed, what has been paid and what is outstanding. Denial trends are not being tracked. There is no consistent month-end review of financial performance.

Signs a transition may be appropriate

Your current billing staff is leaving or unavailable. You are opening a new practice and need billing set up correctly from the start. You have taken on a new payer or specialty that requires expertise your current team does not have.

What Fate MBS is not

We are not a large billing clearinghouse. We are a small, hands-on company that works closely with each practice. If you need a high-volume, low-touch billing service, we may not be the right fit. If you need someone who will understand your practice and communicate directly, we likely are.

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Prospective Clients

Practice Readiness Assessment

Before engaging outside billing support, it helps to understand where your current process stands. These questions are a starting point.

Claims and collections

What is your current collection rate? How many days on average does it take for a claim to be paid? What percentage of your claims are denied on first submission? How are denials currently being worked?

Accounts receivable

What is your total A/R balance? What percentage is over 90 days? Are there payers with a disproportionate share of your outstanding balance? Is there a defined process for following up on aging claims?

Workflow and systems

What EHR and practice management system do you use? Who is currently responsible for billing? Is there a defined process for prior authorizations and referrals? Are claims being submitted within 48–72 hours of the date of service?

What to bring to a consultation

You do not need to have answers to all of these questions before reaching out. Fate MBS can help you identify where the gaps are. Bringing a recent A/R aging report and a summary of your top denial reasons is a useful starting point.

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Prospective Clients

What Onboarding Looks Like

Transitioning billing support should not create more disruption than the problem it is solving. Here is how Fate MBS approaches the process.

Step 1: Understand the problem

We begin with the issues creating the most financial or administrative strain. This is a direct conversation — not a lengthy intake form. We want to understand what is not working before we discuss what we will do.

Step 2: Review the current process

We examine the relevant workflow, systems, payer requirements and outstanding work. This includes a review of your current A/R, denial patterns and any active authorizations or credentialing items.

Step 3: Define responsibilities

Your practice receives a clear understanding of what Fate MBS will manage and what information is needed from your team. Responsibilities are documented so there is no ambiguity about who is handling what.

Step 4: Communicate progress

Work, findings and concerns are documented so your team is not left wondering what is happening. You will know what has been submitted, what has been paid, what has been denied and what is being followed up.

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Prospective Clients

Systems We Work With

Fate MBS has experience working across multiple EHR, practice-management, clearinghouse and payer systems. This list is provided to help practices understand our familiarity — not to imply a partnership or certification.

EHR and practice-management experience

ModuleMD, Veradigm/Allscripts, Tebra, CollaborateMD, Therap, Patient Fusion, Elation, KIPU, Alleva, Ritten, Praxis, EyeMD, SimpleCare, AKMIS.

Clearinghouse, laboratory and payer tools

Availity, Alaska Medicaid MMIS, Quest, LabCorp, LabDAQ, Authorize.net.

Working with systems not on this list

Most billing and practice management platforms share similar workflows. If your system is not listed, that does not mean we cannot work with it. We are comfortable learning new platforms and have done so with each new client.

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