Can providers charge more than EOB?
Asked by: Johnathon Fisher | Last update: November 25, 2025Score: 4.9/5 (62 votes)
Why is my bill higher than my EOB?
Could be what is called late charges that just might not have gotten processed through the insurance yet, or your insurance split the claim and there will be another EOB that is added together to match the totals.
What if EOB and bill don't match?
You should use what you learn to review your EOBs and billing statements carefully. Here are some things to look for: If the dates of service and description of services on your EOB and billing statement aren't the same, or if they don't match other records you may have of the visit, contact your doctor's office first.
Can a provider charge more than the allowed amount?
Under certain circumstances, if your provider is out-of-network and charges more than the health plan's allowed amount, you may have to pay the difference (see “balance billing”). Balance Billing – When a provider bills you for the balance remaining on the bill that your plan doesn't cover.
Why do doctors charge more than insurance will pay?
It is entirely due to the rates negotiated and contracted by your specific insurance company. The provider MUST bill for the highest contracted dollar ($) amount to receive full reimbursement.
Why We Pay Providers Based Off Your Explanation of Benefits (EOB)
What is the allowed amount on an EOB?
The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.” If your provider charges more than the plan's allowed amount, you may have to pay the difference. ( See.
What if the doctor charges me too much?
Your health insurer will review your complaint and should tell the provider to stop billing you. If you do not agree with your health insurer's response or would like help from the California Department of Insurance to fix the problem, you can file a complaint with us online or by calling 1-800-927-4357.
When a provider's fee exceeds the allowed amount?
Anything billed above and beyond the allowed amount is not an allowed charge. The healthcare provider won't get paid for it, as long as they're in your health plan's network. If your EOB has a column for the amount not allowed, this represents the discount the health insurance company negotiated with your provider.
Can insurance charge more than out-of-pocket maximum?
Costs above the allowed amount: Most plans set an allowed amount for various services. If a doctor or facility charges more than that, your plan is not going to cover that cost. This means it will not be applied to your out-of-pocket maximum either. Make sure to check the details of your plan.
What is the maximum allowable charge?
Maximum Allowable Charge (MAC) — caps payment for services provided by an out-of-network dentist at a scheduled amount, the Maximum Allowable Charge.
What is the provider responsibility on the EOB?
Provider Responsibility Amount: Amount of the billed charges that the provider covers. Network providers shouldn't bill you for these charges — but out-of-network providers can bill you for them. Amount You Owe: Amount you pay the provider when you get their bill.
What if EOB says I overpaid?
If you've already paid more than your EOB says that you owe, you will need to request a refund from your provider or facility directly. If you need help with this, talk to a member of your Care Team right away. Your Care Team can advocate for you.
How accurate is EOB?
If the patient is responsible for paying some or all of the charges, the medical office will use the EOB to generate a bill that's sent to the patient for their portion of the charges. EOBs tend to be quite accurate, but there can sometimes be errors.
What happens if EOB and bill don't match?
If you have a doctor's bill that cannot match one or more EOBs, it is likely that your insurance has not been applied to that bill. This can happen for a number of reasons. A common issue is that the doctor filed the claim to an outdated insurance policy or the name or birthdate did not match our records.
How would you handle an overpayment from the insurance carrier?
When an insurance carrier overpays, the first step is to double-check and confirm the mistake. When the payer acknowledges the overpayment, they should reprocess the claim and request the return of the excess amount.
How to get money back from a doctor?
Federal Protections Under the No Surprises Act, effective since 2022, healthcare providers must give you a good faith estimate if you're not using insurance. If your final bill exceeds this estimate by more than $400, you can dispute it. You can also reach out to the National No Surprises Help Desk for support.
Why am I paying more than my out-of-pocket?
Also, costs that aren't considered covered expenses don't count toward the out-of-pocket maximum. For example, if the insured pays $2,000 for an elective surgery that isn't covered, that amount will not count toward the maximum. This means that you could end up paying more than the out-of-pocket limit in a given year.
Can insurance companies charge more?
While it can seem arbitrary, there are actual reasons you can see your price go up and down. Car insurance rates can change based on factors like claims, driving history, adding new drivers to your policy, and even your credit score.
What if I need surgery but can't afford my deductible?
In cases like this, we recommend contacting your insurance, surgeon, or hospital and asking if they can help you with a payment plan. Remember that your surgery provider wants to get paid so they may be very willing to work with you on a payment plan.
What is maximum allowable fee?
Maximum Allowable Fee means the maximum dollar amount that the agency will pay a provider for specific services, supplies and equipment.
Do I still pay copay after out-of-pocket maximum?
If you've already bought a plan, you can look at your copayment details and make sure that you'll have no copayment to pay after you've met your out-of-pocket maximum. In most cases, though, after you've met the set limit for out-of-pocket costs, insurance will be paying for 100% of covered medical expenses.
What does the allowed amount on the explanation of benefits EOB refer to?
The explanation of benefits lists the cost of your care, and how much your health insurance company will pay. “Provider Charges” is the amount your provider bills for your visit. “Allowed Charges” is the amount your provider will be paid. This may not be the same as the Provider Charges.
Can doctors charge more than insurance pays?
If in network, a doctor should never charge more than the negotiated rate with the insurance company less the plan benefit(copay, coinsurance ,etc). If the doctor is out of network there is unfortunately nothing regulating what the charge is. If the insurance company does not pay what the provider chooses to bill….
What are unethical billing practices?
These may include sudden and significant bill increases without transparent explanations, discrepancies between agreed-upon rates and invoiced amounts, and vague or inconsistent billing practices.
Can you sue a doctor for overcharging?
If you're getting overcharged and the medical provider won't play fair, small claims court might be a good option. When you sue in small claims court you level the playing field. The medical provider will need to defend their billing practices in front of a judge.