Allowed Amount – Medical Billing Terminology

Hello and welcome to another issue of my blog!  Just as a reminder I have 4 kinds of blogs and you can find out all about them at the bottom of this post. 🙂

This post is for my medical billing series.  Whether you are in the medical industry or not, this post IS FOR YOU!!  Everyone visits doctors – either because they are sick are trying to prevent sickness.  Either way, this series is to help you understand the crazy world of medical billing.  I will be posting on everything from billing terminology to crazy diagnosis codes.

img_5317Today, I am discussing something that many people do not understand – Allowed Amount.  What does this mean?

If you read my post, How to Read Your Medical Bills – Is it Even a Bill? then you may already understand what this means.  (And if you haven’t read it, you should grab a cup of tea – or coffee if you aren’t allergic to the bean like me,☹ find a comfy spot and read it.)

However, whether you have read it or not, I Continue reading


How to Read Your Medical Bills – Is it Even a Bill?

Ok… so first things first.

What I mean by “medical bills” in the title is literally just that.  It is a “BILL” sent to you for a balance that the sender is claiming that you “OWE” them.

The reason I feel led to be so specific is that often times an insurance company will send correspondence to one of their members and it appears to be a bill when it isn’t a bill at all.  In fact, most of the time it will be what is called an EOB (Explanation of Benefits).

First, let’s talk a little about EOB’s.

An EOB is simply what it stands for – an explanation of the benefits the insurance company provided to the Patient and Guarantor.  Depending on the insurance company, EOB’s can contain various information. It can contain some or all of the following things:

  • Patient Information – This is the person that received the medical services.  It can include the patient’s name, address, date of birth and insurance ID/Group number.
  • Guarantor Information – This is the name of the person that is the owner of the insurance policy.  It can include the same type of information as the patient.
    Example #1: Jane Doe is seen at the doctor.  Her husband John Doe works for ABC company and has an insurance policy for himself and his wife Jane.  The EOB would list Jane as the Patient and John as the Guarantor because he owns the policy through his employer.
    Example #2: Jane Doe is seen at the doctor.  She works for XYZ company and has an insurance policy for herself and her husband John.  The EOB would list Jane as the Patient AND the Guarantor because she owns the policy through her employer.
  • Facility/Physician Information – This could include information such as the name of the doctor who treated the patient or the facility where the patient was seen, their address, phone number, NPI (National Provider Identifier) and Tax ID.
  • Service Information – This section will include the date the patient was seen, the procedures that were done, what was charged and then several other monetary values that can be very confusing.  (That is exactly what this publication is going to go over. ☺)
  • Remark Code Details – These are codes that explain WHY the charges were processed the way they were.

If you receive this from your insurance company – it is NOT A BILL!!  Even if it states that you are responsible for a part of the balance.  A bill will come directly from the physician or facility – because that is who you owe if indeed there is a patient responsibility balance.  I’ll go over that more toward the end of this article.

When you receive an EOB, you will want to inspect it.  Like I mentioned in my “I am Angry” article, doctors are amazing and dedicate themselves to years of education to learn how to keep us healthy and to save lives, but not necessarily how to bill for it.  Some of them do get certified and learn the specifics, but many do not.  They hire coders and billers to take care of medical claims and billing and often times, the staff is just not trained properly.  Not to mention – we are all humans and are certainly make mistakes.


So first, you’ll want to look over the document and make sure things like dates, names, procedures, etc. are all accurate.  Now let’s get down to the numbers…

The numbers can really be confusing.  What the heck does “allowed amount” even mean and what are these crazy “adjustments” for?!

There is a lot of information in the Services section, but I am basically just going to explain the monetary values.  I will write an article on each one of these topics that is more in-depth and will try to remember to come back here each time an add a link to each section, but here is the basic breakdown:

Billed amount –  This is the amount that the doctor/facility billed the insurance company.  Now I know that some of you may be thinking these prices are ridiculous, but trust me – there is a reasonable explanation.  You honestly have no control over the amount that is charged here.  I will say that most doctors and facilities offer a significant discount for patients that have no insurance – but to be clear – that isn’t always the case.

Allowed amount – This is the amount that the insurance company is willing to pay for the service provided to this doctor/facility.  Every insurance company has a different amount they are willing to pay for each service – it is not the same amount across the board.  You have no control over this amount either.  This is an agreed upon amount between the doctor or facility and the insurance company.  The list of pricing is called a Fee Schedule.

Deductible amount – This is the amount you are being charged for the agreed upon amount of deductible you chose when selecting your insurance plan.  If you feel like this amount is incorrect, you need to call your insurance company – not the doctor/facility.  If the insurance company determines that they processed the claim incorrectly, they will correct it and send the updated information to the doctor/facility.

Coinsurance amount – Just like your deductible, the coinsurance is an agreed upon amount between you and your insurance company.  The doctor/facility has no control over this.  So if you feel this amount is listed in error – again, call your insurance company, not the doctor/facility.

CoPay amount – This is also an agreed upon amount between you and your insurance company.  However, the doctor/facility should have verified your insurance and any copay amount that should be charged prior to your appointment.  This amount should have been collected at the time of service.  If the doctor’s office told you “not to worry about it”, this does not mean you don’t have to pay it.  It just means, for whatever reason, they decided to not make you pay it up front and they were going to bill you for it.

Note: To be clear, Deductible, Coinsurance and CoPay amounts are the responsibility of the Patient/Guarantor.  The doctor/facility does not have anything to do with deciding these amounts.  If you feel like the amounts on the EOB are incorrect you need to contact the insurance company.  If you were charged something OTHER than what is listed on the EOB, you should contact the doctor/facility at that point.  If they do correct the error and issue any necessary refunds, then you need to contact your insurance company and let them know.  They will contact the doctor/facility directly.  You can even ask them if they can do a three-way conference type call so that you can hear the response.  Not all insurance companies will do this, but some will.

Adjustment or Other Adjustments – This one can get confusing, but it is really very simple.  Ok, so here is an example:
– A patient goes to the see the doctor for a sore throat, fever, and cough.
– The doctor examines the patient and determines the patient has an upper respiratory infection.
– The doctor codes the office visit with CPT 99214 – Don’t concern yourself with the codes at this point.  This example is really just about the adjustment amount.
– The doctor has determined the billed amount in his/her office for this service is $200 (this may or may not be accurate to what your doctor charges for this service – I’m just using it as an example for easy math purposes.)
– The doctor’s billing department submits the claim to the patient’s insurance company.
– The contract between the insurance company and the doctor states that the insurance will allow $80 for CPT 99214.  This means every time this doctor submits a claim with CPT 99214 listed on it, to this specific insurance company, he/she will get paid $80.  (Not necessarily by the insurance company – keep reading!)
– If the doctor billed $200 and only got paid $80 – there is still $120 remaining.  This is the “adjustment”.  It is actually called a contractual adjustment.  This means that any difference in between what the doctor billed and what the insurance company allowed must be adjusted off.  The doctor cannot bill this amount to the patient.

Provider Paid – This is the amount the insurance company actually paid the doctor/facility.  The above seems pretty simple – right?  $200 (billed) – $80 (allowed) = $120 (adjusted off).  Here’s the thing: just because the insurance company “allowed” $80 for CPT 99214 – does NOT mean that is what they are going to pay the doctor!!

If your EOB says:
Billed $200
Allowed $80
Adjusted $120
Paid $80
Then that means the insurance company paid the doctor EVERYTHING that is owed to him/her for that visit.  To be clear – if the allowed amount and the paid amount match – you owe nothing.  Period.

However, if the allowed amount and paid amounts are different – that means that the patient is responsible for the difference – which will either be deductible, coinsurance or copay.

As an easy example, say you go to the doctor and the person at the check-out counter tells you that you owe $20 for a copay, then the EOB would read more like this:

Billed $200
Allowed $80
Adjusted $120
Paid $60
See the allowed is $80 and the paid is $60.  There is a $20 difference – that is the copay that you are responsible for.  If you paid it upfront on the day you were at the doctor, then you owe nothing.  If you didn’t then you will still be responsible for that difference.

In that case, the EOB would actually read like this:
Billed $200
Allowed $80
Deductible $0
Coinsurance $0
CoPay $20
Adjusted $120
Paid $60.

In addition, if you haven’t fulfilled your deductible yet and you are responsible for a copay, it could look like this:

Billed $200
Allowed $80
Deductible $60
Coinsurance $0
CoPay $20
Adjusted $120
Paid $0

Notice in that example, the insurance company allowed $80 – based on the contract with the doctor, but did not actually pay the doctor anything.

The allowed amount is what the insurance company and doctor agree the doctor will get paid for the procedure – but the payment could come from the insurance company, the patient, or a combination of the two.

This brings us all the way back around to the bill.  Remember an EOB is not a bill – it just explains how the insurance processed your claim so you will know if you need to expect a bill from the doctor/facility.  That is why it is SO important to review your EOB’s.  If your insurance company doesn’t mail them to you – they may only offer them online.  Make sure you look for an EOB for EVERY visit you make to a doctor/facility.

When you get an actual bill, it will be from the doctor or facility.  For every bill you get, you should have a matching EOB.  If you go see the doctor for a sore throat at his/her office, you should be able to obtain an EOB after the doctor files the claim and the insurance processes it.  If you receive a bill from a doctor and have not received your EOB, you need to contact your insurance company or log in to their member portal to view your EOB or request that one is sent to you.  Your doctor bill and EOB should match exactly in regards to amounts allowed, paid, due, etc.

The title of this post is:

How to Read Your Medical Bills – Is it Even a Bill?

You should be able to determine from an EOB what you should owe a doctor/facility and why.  If there is any difference – something is wrong – call your insurance company asap!

In the case of a self-pay patient – meaning you have no insurance and only pay cash – it is a little different.  You should ask every doctor/facility for all of the following things:

  • A list of each CPT or Procedure code and description that you are being billed for.  The specific CPT codes won’t matter to you, but the descriptions will.  This holds the doctor accountable for what they are charging and lets you know exactly what the doctor is stating he/she did for you.
  • What is the billed amount of EACH code?
  • What is their self-pay policy?  (Do they offer a self-pay discount and if so what are the terms.  This is very important because some offices only offer a self-pay discount if you pay in full at the time of service.  Some offices only offer a self-pay discount if it is asked for!  These are things you really should ask when making the appointment.)

This post may be a little lengthy, but hopefully it was helpful.  Please take a moment to scroll up top and add your email to the subscribe box so that you will be notified every time I post.

Full disclosure: Medical Billing is something that I am very passionate about.  I am a patient somewhere and so are all of my family members and it is very important to me that our claims are handled as thoroughly as I handle other people’s.  I am a work at home mom and not all of my posts are medical billing related.  Not only am I opening my own Coding & Billing Educational Consultant business in 2018, I have been an Independent Consultant for a children’s book company since 2011 and I own a photography company with my daughter.  Also – I am a wife-ish, mother, self-employed nerd and I post about all kinds of things.  I would love to share them with you.

Please take a moment to comment or ask questions below.  You can also find me all over social media:

Twitter: WAHMCat & Medical Billing
Instagram: WAHMCat
Youtube: WAHMCat (I don’t have a video to go with this post, but I’m working on one – Still go subscribe! ☺)
Usborne: Usborne website, Facebook Page
Photography: Shutterbug & Co., Facebook Page

Thanks for reading, commenting, sharing, following and subscribing.  You guys are the best.


Cat Clayton, CPC, CPB, CPMA
PO Box 121861
Fort Worth, TX 76121


Day 6 – Taco Tuesday Baby!

Hi ya’ll!!  Today was a very awesome day!  Why, you ask?  Because it’s TACO TUESDAY BABY!! On this 6th day of my social media challenge, Tuesday December 2nd, I am thankful for #TacoTuesdayBaby – also #yummy! 🙂

Every Tuesday for the last few years, my family has pretty much eaten the same thing every Tuesday.  Unless I was sick or tending to a sick kiddo or some other craziness happened, I went and picked up Taco Tuesday!!  It has become a ritual in my home that I really love.

It started with a few Tuesday’s here and there because it was inexpensive, tasty and easy.  Then it just became…a thing.  Then when I had little man it also became a ritual that the MIL (the Misters mommy) came over every Tuesday to visit her newest grandbaby.  I started picking up tacos for her too.  Now, I really look forward to Tuesday nights and here is why:

  • TacoCat is spelled the same backwards. 🙂  Ok…so that isn’t one of the reasons, but it is still some useful useless knowledge that you may need some day! 😉
  • Tacos are yummy and there are sooooooooo many options!!  Corn or flour tortillas?  Beef, chicken, carnitas, veggie…blah blah blah?  Lettuce? Tomato? Cheese? (duh.) Sour cream? Guacamole?  Or do you like street tacos with onions and cilantro?  #yummy!!
  • All 3 of my kids sit around the table with the MIL and we always have good conversation.  Nothing can beat that. 🙂
  • I am teaching my children the value of spending time together.
  • Lots o’ food for NOT lots o’ money!

It’s a total #WinWin.

Today was an easy pick for what I’m thankful for!  I’ve known ever since I started my challenge what I would be thankful for the very first Tuesday. 🙂

I can’t wait to hear/read/see your posts!!  If you guys play along on any social media sites please use the hashtag: #365smc That way I can follow along all year and give you guys some shout outs!!

Here is the link to my YouTube channel: Cat’s YouTube Channel: Obliviously Awesome – Go find the Day 6 video and let me know what ya think!!! 🙂

Here is where you can find me:

VLOG: www.youtube.com/user/OblivioislyAwesome
BLOG: www.WAHMcat.wordpress.com
TWITTER: https://twitter.com/wahmcat
INSTAGRAM: www.Instagram.com/ObliviouslyAwesome
FACEBOOK: https://www.facebook.com/pages/Obliviously-Awesome/311528022376074
PINTEREST: www.Pinterest.com/wahmcat

See ya’ll tomorrow! 😀

Love ya lots, like tator tots!!

Love, Cat




14,000 things to be happy about.

**November Daily Blog Self-Challenge**

Friday, November 1st, 2013 (Better late than never?!)

To begin my challenge I thought it would be nice to do a post about the things I am thankful for – since this is the month that lots of people celebrate the very same.  Everything that I am thankful for also makes me very happy – so I decided to take inspiration from this great little book I found at the Half Price Bookstore.


Every now and then when I am having a rough day I pick up this book and go to a random page and find something new to be thankful for.  Some days it gets really funny… like on page 546 when it says “kitties licking” and “blue light bulbs”…sure I guess those things might make someone happy.  What makes my day is when I flip open to things like on page 209 – “low, rolling thunder in late fall” and “extra kisses” on page 208. 🙂

While flitting through Google to find other bits of happiness I came across the neatest little website.  http://www.thingstobehappyabout.com/  Apparently, this website took motivation from the same book and started a website where others can leave things that make them happy that aren’t already on the list. (What a BRILLIANT idea!)  As of today it lists 146,047 things to be happy about!!

There is also a special link for kids to find something to be happy about too!  Things like “earning a scholarship”, “asking about someone’s day and caring about the answer”, and “biking undisturbed by thought”.  What lovely ideas!

Take a moment and check out the site – it might make your day.

I’m going to leave you with 30 things that make me happy.

  1. My first will just be my life.  This is all inclusive of my family, friends and everything and everyone that makes me…me.  The next 29 things will be things that I have picked from the book that this blog post is titled for. I hope you enjoy. 🙂
  2. “a new canvas” – I have a new love for painting and I really enjoy starting with a new blank canvas and making it what I want.
  3. “sexy music” – I love, love, love me some saxophone.
  4. “leaves becoming a restless golden drift, a wine-red flurry in the wind” – I absolutely love Fall and this little ditty makes me want to sit in the falling leaves and write a poem about why it makes me happy.
  5. “strawberry champagne” – yum.  Just yum.
  6. “peaceful countryside” – nothing sweeter on a Fall afternoon than a drive down a country road.
  7. “Thanksgiving dinners” – my absolute favorite day of the year to eat. everything. in. sight. Period.
  8. “hearthside” – could be very romantic or just relaxing with a good book and a glass of wine.
  9. “a yummy gourmet shop” – yes.  I like to eat. 🙂 …and yummy is good.
  10. “3-D movies” – Love it!!  We have a 3D TV at home and we love it!  Saves a ton of movie from the theater fees and makes a great – inexpensive date night! 😉
  11. “Coca-Cola commercials” – Yes!  Just thinking about it makes me want a coke right now – and I’m a Dr. Pepper kinda gal!
  12. “the purr of a kitten” – I am allergic, but I love kitties!  I would have one tomorrow if the Mister would let me!
  13. “opening a nearby window to let in sounds and smells of spring” – I’m all about the nature.  Good tunes and a nice breeze and sounds of nature – nice afternoon.
  14. “fresh flowers at work” – or anywhere for that matter.  I’m actually considering to add buying fresh flowers for the kitchen every week to my to-do list!
  15. “pre-Christmas hustle and bustle” – I know lots of people hate it…but I love it!  There is just enough people left in the world that enjoy the Spirit of Christmas that makes me feel all jolly. 🙂
  16. “the color, scent, and deliciousness of strawberries” – they can be used for so many things.
  17. “the sweet and simple indulgence of an afternoon nap” – especially outdoors!
  18. “watching it snow” – nothing else need be said about that.
  19. “tickling and silly songs and cookies and hot chocolate in bed” – just a lovely way to make memories.
  20. “the perfect outdoor café where you can hang out with a newspaper, sip, nibble, people-watch” – I don’t really have one of these that I know of – but I can’t wait to find one. 🙂
  21. “this thing called love” – indeed.
  22. “accepting a compliment” – and really mean it when you accept it.
  23. “places to go antiquing” – especially the ones with little tea rooms.
  24. “gentlemen rising when a lady enters or leaves a room” – doesn’t happen much anymore
  25. “recreation and leisure” – all work and no play makes Jack a dull boy…and that is just no fun.
  26. “A word to the wise is sufficient” – makes me happy and is a lovely piece of advice!!
  27. “your best friend and a good bottle of wine” – yes ma’am!
  28. “not just seizing the day but making the day” – absolutely!
  29. “your signature” – who doesn’t practice to make their signature the best?
  30. “photographing children” – seriously the most fun

And that is just a tiny little bit of what makes me happy…there is oh so much more!!
I challenge you to come up with your own list of 30 random things to be happy about and thankful for and link back to this post so your friends and followers can do it too.  When you look for those small things in life it just perks you up.

I wish you all a lovely day! 🙂

It is 3:55 am and I have to be up at 6:30 so I’m hopping in bed for a little nappy poo. After the kids are up and off to school I’ll hop on and get my other blogs on here to catch up to my challenge.



Every Tom, Dick & Harry…

Here is the deal. I don’t mean to be Kurt, but I have a lot going on. {Check out my About Me page Here if you want to know what all that is! Then head over to my Contact Me page and fill out the poll to get your kiddos a free bookmark & sticker! I don’t mean to Russel feathers….but I’m kinda cool like that! ;-)}

A little over a year ago I did what a ton of moms do. I got frustrated! I was burnt out! I loved EVERYTHING I did – but none of it was specifically for me. It was always for the kiddos, the Mister, the dog, my friends, my family…you get the picture. I needed to find that one thing. For me. I wanted to find a hobby that didn’t include getting a Bill in the mail from the credit card company each month. So I started googling “cool hobbies for mom”. Here is what I came up with:

  • Fishing – I know some ladies like it…but it isn’t for me. No way, Jose.
  • Social ReadingJuan-a know what this means? Basically, joining a book club and meeting with people to discuss and dissect the meaning of a particular book.
  • Acting – As fun as that would be, time would be an issue. I don’t see a Tony or an Oscar in my future.
  • Traveling the world – Oh, heck yes! Wade a minute….Damn. There’s that whole “gotta win the lottery” thing. Yeah, so…what’s next?
  • Roller Derby – I don’t think so, Tim.

There were sooooo many things! I found lots of pages like “101 Hobbies for Mom” (which, to be Frank, was part of a great blog that I will now be following! Great stuff!) and “57 Hobby Ideas for Busy Moms” (another great blog I get to Phil my brain to the Max with!) I just couldn’t find anything that was….me when it came to hobbies. I honestly felt the need to Neil on my knees and pray to the Heavens to send something my way to keep this mommy from going insane with the day to day of her crazy life. Then all of a sudden….Hark – the Harold Angel‘s sing…. ok…you got me – there was no singing, but I remember thinking, “Man, these moms have the coolest lives! I wish I could pretend I was half that cool! Next thing I know, a lovely little Ray of sunshine just thumped me in the head and said, “Hey dum-dum! YOU CAN!!”

6af9e90e54fd11e19896123138142014_7So…I researched blogging for about a year to make sure it was something I could really identify with. Something that would hold my interest, motivate me and help me grow – personally, spiritually and professionally. I came to a decision – I. LOVE. BLOGGING. I set up a test blog and played with different types of posts. There are a lot of things you can do with a blog! From reviewing products, giving advice, and marketing a small business to sharing recipes, sharing inspiring journey’s, and even specialty blogs that focus on important topics like Adoption, Homeschooling and Charities. Where the heck was I supposed to focus my blog? I didn’t want to be like any Tom, Dick & Harry and I’m nothing extraordinary. And it’s not like there is a Manuel to tell me the Do’s & Dont’s of blogging. Well, there probably is – but there is no way it could apply to everyone! Roger that?

Well…I have Ben called special a time or two or three. (Yes, it was by my children – but so what – they are brilliant kiddos!) I just want to be a part of something BIG!!! I want to throw down a full Nelson on this blogging thing and make something of it!! The big question – What am I passionate about? I like lots of things…but I read once that a “real” writer creates from the heart. Actually, I just made that up. Clever Trevor, huh?! I just want to be a real life Arthur – the kind that writes about balloons, doodles, oodles of canoodles (that means LOTS of hugs and kisses!), bubble baths, controversy, sporks and other nonsense. More specifically I plan to I plan to make you laugh (a lot), make you cry (a little) and make you want to change the world. It’s all about paying it forward.


There it is Jack. My Earnest plan to entertain you to the gills with….well….something. Something special. I make no promises, but I’ll do my best. I promise. 😉


Officially Title: Award Nominated Momma Blogger :)


Yippee! Look at me…all official and stuff!  Now before you all go and start sending me congratulatory gifts and all (no, really – go ahead) I need to thank the awesome gal that nominated me!  Check out her blog here: “The hilarious, mental side of motherhood“.  I love reading her posts!  This one in particular is one that I identify with: “Invasion of the Mom Snatcher” – simply hilarious!  That is the thing about this crazy blogging world!  I just love it!!  I’ve met so many diverse people and I am loving it.  I am a brand new blogger but have BIG plans for my future in this virtual world.  I plan to really make a difference – I know…I know…don’t we all?  But I am a redhead – so I may be a little stubborn – which usually (definitely not all the time) helps me out.  In this particular case I’m going to cross my fingers for the whole “fairytale ending”. 🙂

However in my short time in this virtual world – I have “met” some super talented people.  So I am going to nominate a few of them for this award too! 🙂

– Check out “Cute Overload” a group of people that put up the absolute cutest things on the internet!  Anytime I need a smile (or to get my little one’s mind off the fact that ma-maw just left) I can count on this blog to deliver in the form of tiny pig snout and the like! 🙂
– Then head over to this Super Dad’s page, “The Real Full House” and read his journey.  This blog is modeled after the 90’s sitcom, “Full House”.  After his wife passed away he had to step up and play mom and dad to his girls.  His blog is refreshing and funny.  Great read.
– And then you should peek in on my first ever follower “Mommas Got A Brand New Bag“.  She is the mom of 4 (and 2 fur babies) and her blog is often funny and always full of amazing give-a-ways & contest info!  All of her kiddos names start with a “D” and she is Darn funny!
– For my fellow artistic followers you should pop over to check out “Stories from home” – an awesome blog with absolutely AMAZING pictures and a sweet little dog named Oliver. 🙂  I love taking a peek at the newest things on this blog as often as I can. It’s like getting that first breath of fresh air outside the grocery store when you’ve been stuck behind the crazy lady with 3 gallons of ‘eau de toilet water’ in line ahead of you.  A nice sweet breath of fresh air. 🙂

I look forward to meeting lots of new people on this blogging adventure! 🙂  See ya out there…..