Disclaimer: This is for general informational purposes only and does not constitute legal advice. Consult a qualified attorney for advice specific to your situation.
Detailed Answer
A statement of account—often sent after you receive medical or professional services—breaks down what you owe after third-party payments. In Pennsylvania, providers follow industry best practices and state transparency requirements (see 40 Pa. Cons. Stat. § 991.1703) to show exactly how insurance and government program payments affect your balance.
On a typical statement you’ll see these key columns or sections:
- Charges: The full amount billed for each service or item.
- Payments & Adjustments: Credits applied to your account, including payments by insurance companies or government plans.
- Balance Due: The remaining amount you’re responsible for.
Insurance payments and government program reimbursements (like Medicare or Medicaid) usually appear in the Payments & Adjustments section. They often show as two line items:
- Insurance Payment: The actual amount your insurer remitted to the provider.
- Contractual Allowance or Adjustment: The difference between the provider’s full charge and the negotiated rate the insurer or government program allows. This amount is not billed to you.
For example, if a provider’s full charge is $200, and Medicare pays $120, you’ll see:
- Charges: $200
- Medicare Payment: –$120
- Medicare Adjustment: –$50
- Balance Due: $30
This breakdown ensures you only pay $30—the portion not covered by the program.
To review your insurer’s Explanation of Benefits (EOB) and confirm these numbers, visit the Pennsylvania Insurance Department’s resource: EOB Guidance. Providers often mirror that EOB detail on your statement of account.
Helpful Hints
- Check the Payments & Adjustments column for all third-party credits.
- Look for terms like “allowance,” “write-off,” or “discount”—these are not your out-of-pocket costs.
- Compare your statement to the insurer’s EOB to spot discrepancies.
- Contact the provider’s billing office if you see a payment or adjustment you don’t recognize.
- Save your statements and EOBs for tax or reimbursement purposes.