EOB vs EOP in Healthcare

The healthcare industry has always been one of the most complex sectors for business operations. It requires the utmost attention to detail and knowledge to ensure your facility operates legally and without setbacks. One of the most challenging aspects of running a healthcare organization is proficiency in medical billing and coding, which plays a vital role in managing your revenue cycle and financial stability.

To support healthcare providers in overcoming these challenges, we offer complete medical billing services tailored to optimize your revenue cycle and enhance financial performance. That’s why, in this article, we want to elaborate on the key aspects that set EOB vs EOP apart and their use in healthcare. Because we’ve noticed that many of our clients have a hard time telling them apart, we’ll explain their key components to better grasp their differences. 

What Is EOP in Healthcare?

EOP (Explanations of Payment) is a document issued to providers after a health plan has processed a payment for a claim. Its main goal is to show how the medical services in the claim have been processed and how the payment has been determined. Besides showing that a claim was processed, EOP is a document that outlines the service date, the reason behind the claim, and how much the claim was.

• This document plays a vital role in healthcare business operations because it gives you a detailed overview of the payment process. Keep in mind that EOP is not a bill, meaning no action is required upon receipt. Since the healthcare industry is highly regulated, EOPs allow providers, and insurance payers to have transparent and accurately documented proof of their costs. With the EOP each side has an insight into the financial aspects of the medical services. 

Key Components of EOP

The best way to tell these two documents apart is by familiarizing yourself with their key components. That’s why we’ll first focus on the key elements of EOP before explaining the ones in EOB. 

• Payment details–  detailed description of the amount billed by the healthcare provider and the amount paid by the insurance company for each of the services you’ve offered.
• Adjustments– describes which of the services you’ve billed for have been either discounted or denied and the reason behind the decision.
• Contractual allowances– describes the predetermined rates and allowed amounts for the services provided based on your contract with the insurance company.
• Patient responsibility– describes the amount of money the patient has to pay out-of-pocket based on their insurance plan.
• Remarks or explanations – EOPs may also contain additional notes that further elaborate on the reasons why a certain service payment has been denied or adjusted. 

Source: freepik.com / Photo Contributor: user18526052

What Does EOB Stand For in Healthcare?

On the other hand, an EOB (Explanation of Benefits) is a document that insurance companies send to the provider when a claim gets paid or denied. Since it’s considered protected health information, it provides a detailed explanation of which medical services were covered by the insurance plan.

The main goal of this document is to clarify each party’s payment responsibility by outlining the services provided, the amount billed, insurance payment, and the amount the patient has to pay out-of-pocket. EOBs provide transparency about how the claim was processed and inform the patient of their costs and how much is covered by their insurance.

If the claim has been denied, they also provide a detailed explanation behind the reasons and offer an appeal opportunity. 

Key Components of EOB

Like EOPs, the Explanation of Benefits document consists of specific information about the interaction with the healthcare provider, the care received, the amount covered, and the amount the patient owes to the healthcare provider. That being said, here are the key components that EOBs include within their documentation:

• Patient information– EOBs contain the name and identification number of the patient you’ve provided the billed services.
• Provider details– EOBs must contain the name and identification numbers of the healthcare provider or organization that has offered the services. 
• Claim details– EOBs must include a detailed list of the services you’re billing for, including their date, description, and appropriate medical codes.
• Payment information– describes the amount of money the insurance company has paid for each of the services you’ve billed for.
• Adjustments or denials– describes the reasons behind any denials or payment adjustments.

Source: freepik.com / Photo Contributor: lenadig

Difference Between EOB and EOP

EOBs are intended to inform patients and healthcare providers about how a healthcare claim was processed and the patient’s responsibilities, while EOPs are intended to provide detailed insights into the payment process for healthcare providers. 

Even though both EOP and EOB documentation include patient and provider information, adjustments, and claim descriptions, EOPs have additional components, such as billed amounts, allowed amounts, and patient responsibility.

As you can see, although these documents are quite similar, the number-one factor that helps tell them apart is their use. 

Common Misconceptions

The two most common issues we’ve seen our clients struggle with are terminology confusion and misinterpretation of payment information.

First, we’ve seen many people use the terms EOB and EOP interchangeably, even though they represent two different document types. However, they have their own unique components, audiences, and purposes that set them apart.

The second misconception is often based on document misinterpretation due to the complex technical language used in both EOB and EOP. Familiarizing yourself with the medical terminology and codes in this documentation will enable you to offer clear explanations to patients should they have any questions. 

Conclusion

After elaborating on the difference between EOB vs EOP, we recommend you familiarize yourself with their key components and uses to easily distinguish them.  Explanation of Benefits focuses on informing the patient and healthcare provider how the claim has been processed, while the Explanation of Payment elaborates on the details of the payment process. Furthermore, understanding their differences leads to more effective communication and further billing process optimization. 

Since we’re fully aware that running a medical organization has numerous complexities regarding business operations, we want to help both the healthcare and insurance industries through our customizable outsourcing services. Our team at CLICKVISION BPO specializes in healthcare process optimization, such as providing full revenue cycle management services, and is ready to meet your diverse needs in both sectors. So, contact us today and discover how our tailored solutions can streamline your back-office operations and help you drive better results!