Navigating the “this is not a bill” for your medical services

Health care is complicated for the average consumer. Heck. It's even confusing for health care professionals. I’ve been in the industry for (dare I say it?) 30 plus years, and I was recently thrown for a loop by my health plan’s Summary of Payments (SOP). What’s an SOP? It’s that piece of paper we all get from our insurance company with THIS IS NOT A BILL printed right at the top. But if it’s not a bill, what is it?

After a recent preventive screening, I got the expected SOP in the mail. An SOP explains the costs for a service, including what the insurance company paid and what the member can expect to pay. Massachusetts recently switched to the SOP format. Insurers used to send a similar document called an Explanation of Benefits, or EOB. You can read what insurers are required to include in the SOP on the Division of Insurance website.
At the top of my SOP, as always, it reminded me that this wasn’t a bill. But down at the bottom it did show that I could expect an actual bill – for $400! – from my provider very soon. From my perspective, the SOP might as well be a bill. It felt like I was already out $400.

But was I?

The itemized charge was for the recovery room. Odd, because I couldn’t just wake up from my procedure and walk out of the outpatient surgery setting?

So I called my health insurer. They looked into it and discovered that the recovery room care I received had been billed incorrectly. They contacted the provider to correct the error. The provider did so, and the actual bill I received (and paid) was correct. In the end, this made everything easier for me, my insurer, and my provider. And it was all because of the SOP.

It’s important for patients to understand the purpose of the SOP – to clearly explain their costs – before they panic (like I did) or before they pay their bill. My 89-year-old mother, who only knows she got a paper that states she owes $400, would have written a check immediately and added another layer of complication to the process of sorting out the costs.

After your patients get an SOP, it’s a good idea for them to wait for the actual bill before sending in a payment. They can also call their insurer for help understanding their costs for the service. They should write down the date, person you spoke with, what the next steps are and when they expect a response or resolution.

NHP recently provided an overview of the SOP on page 6 of our Summer member newsletter.