Her statements arrive by mail or through a patient portal, and most of them say somewhere that this is not a bill. Read that line first. It means the insurer has processed a claim and is telling you what it covered, what it reduced, and what the provider may still ask you to pay. The amount you owe is usually a separate number on a separate bill from the provider's office, and the two often do not match on the first try.

Local option: New Plan Care gives families in the St. Louis area in-home help so a parent can stay home: companionship, help with bathing and dressing, meals, and overnight care. Call (314) 405-0887.

What pushes the amount up

Four things move the number most often. The first is whether the provider was in your wife's network on the day of service, since an out-of-network charge can leave a larger balance. The second is whether her deductible for the plan year has already been used up or still has to be met. The third is whether a service was billed under a code the plan limits by count, by place of service, or by how often it can repeat. The fourth is whether one visit was split into several charges, each with its own share of cost.

What pulls the amount down

The insurer's allowed amount is usually lower than the billed charge, and the difference is supposed to be written off by an in-network provider. If a bill shows the full charge with no adjustment, that is the first thing to question. Some providers also have a financial assistance or charity policy that you can apply for in writing, and many will set up a payment plan if you ask before the account goes to collections.

What to check before you pay

Put the explanation of benefits next to the provider bill and compare them. Check that the dates of service match. Check that the provider's name and network status match what the insurer printed. Check that the billed amount minus the adjustment equals the patient share shown. Check that your wife's name and member number are spelled correctly. If a single line does not match, call the billing office and ask for an itemized bill with the codes listed, and ask the insurer for the reason code it gave for each reduction.

Questions to ask the billing office

Was this provider in network on the date of service. What is the allowed amount for each code on this bill. Has the deductible been applied, and if not, why not. Is there a payment plan, and what is the monthly amount. Is there a financial assistance policy, and what form or letter do I need to apply. Who do I call if the insurer and the provider give different numbers. Write down the name of each person you speak with and what they told you, and keep that log with the statements.

What you decide and what you do not

Whether to pay now, whether to dispute a line, and whether to appeal a denial are decisions for you and your wife's family, and sometimes for a benefits counselor or an attorney who handles these cases. This article does not tell you what her plan must cover or what a particular provider is required to do. It only gives you the order of checks so the bill you pay is the bill you actually owe.

Your own statements

The same logic works for your own medical bills, and it is worth using before a visit rather than after one. Ask whether the office is in your plan's network, what the expected patient share is for the visit, and whether a payment plan exists. Once you have those answers in writing, the statement that comes later is easier to check against them.

The Explanation of Benefits Is Not a Bill. Find Out What Drives What You Owe