Understanding the Billing Process
From your appointment to your final bill—here's how healthcare billing works and what to expect along the way. Understanding the process can help reduce confusion and anxiety about costs.
How Healthcare Billing Works
Understanding the relationship between you, your provider, and your insurance
Healthcare billing involves a conversation between three parties: your provider (our practice), your insurance company, and you. After each appointment, we submit a claim to your insurance, they process it and determine your cost share, and then you receive any remaining balance.
This process takes time—typically 3 to 6 weeks from your appointment to your final bill. This is completely normal. You'll receive documents along the way that help you understand what's happening with your claim.
Billing Is a Process, Not an Instant Transaction
The Billing Timeline
What happens from your appointment to your final bill
Service Delivery
Day 0You attend your therapy appointment. If you have a copay, it may be collected at checkout. Your therapist completes their clinical documentation for the session.
Claim Preparation
Days 1-3Our billing team prepares your claim with the appropriate procedure codes (like 90834 for a 45-minute therapy session) and diagnosis codes. We verify all information is accurate before submission.
Claim Submission
Days 1-7We submit your claim electronically to your insurance company. Most claims are submitted within a few business days of your appointment.
Claim Processing (Adjudication)
Days 7-21Your insurance company reviews and processes the claim. This is called "adjudication." They verify your eligibility, check that the service is covered, confirm network status, and calculate how costs are shared between them and you.
Typical processing times:
- • Commercial insurers: 7-21 days (required by law within 30-45 days)
- • Medicare: 14-30 days
- • Complex claims may take longer
EOB Generated
Days 14-28Your insurance sends you an Explanation of Benefits (EOB)—either by mail or through their online portal. This document shows how your claim was processed and what you may owe. Important: An EOB is not a bill.
Payment to Provider
Days 14-30Your insurance sends their payment directly to our practice. We receive the same information that's on your EOB, showing what was paid and what remains your responsibility.
Patient Statement
Days 21-45This is your bill. After we receive payment from insurance, we send you a statement for any remaining balance—your deductible, copay, or coinsurance amount. This should match what your EOB shows as "patient responsibility."
Total Timeline: 3-6 Weeks
From your appointment to receiving your final bill typically takes 3 to 6 weeks. This is normal—your claim is simply moving through the standard process.
Understanding Your Explanation of Benefits (EOB)
What it is, what it means, and how to read it
An Explanation of Benefits (EOB) is a document from your insurance company that explains how they processed your claim. It shows what was billed, what they covered, and what you may owe. You'll typically receive an EOB for each claim, either by mail or through your insurance company's online portal.
An EOB Is NOT a Bill
Key Fields on Your EOB
| EOB Field | What It Means |
|---|---|
| Date of Service | The date of your therapy appointment |
| Provider | Your therapist's name and/or our practice name |
| Procedure Code (CPT) | A code describing the service. Common therapy codes:
|
| Billed Amount | What your provider charged for the service (e.g., $180) |
| Allowed Amount | The negotiated rate between your insurance and in-network providers (e.g., $160). This is the maximum your plan will consider for payment. |
| Adjustment/Not Covered | The difference between billed and allowed amounts. For in-network providers, this is a contractual write-off—you don't pay it. |
| Deductible Applied | How much of this claim counts toward your annual deductible. If your deductible isn't met, you'll see the full allowed amount here. |
| Copay/Coinsurance | Your share after the deductible is met—either a flat copay (e.g., $30) or a percentage (e.g., 20% = $32). |
| Plan Paid | The amount your insurance paid to the provider |
| Patient Responsibility | What you owe. This should match your bill from us. |
| Remark Codes | Codes explaining any adjustments, denials, or special processing. There's usually a key or legend explaining these codes. |
Reading Your EOB: Real Examples
During Deductible Phase
Plan: $1,500 deductible, 20% coinsurance
Deductible met so far: $0
Full allowed amount applies to deductible. Plan pays nothing until deductible is met.
After Deductible Met
Plan: $1,500 deductible, 20% coinsurance
Deductible met: $1,500 (fully met)
With deductible met, you pay only 20% coinsurance. Much lower cost per session.
Compare Your EOB to Your Bill
Common Billing Situations
What to expect in different scenarios
If it's early in the year and you haven't met your deductible yet, you'll pay the full allowed amount for your visits until your deductible is satisfied.
Example:
- • Your deductible: $1,500
- • Allowed amount per session: $160
- • You'll pay $160 per session until you've paid $1,500 total
- • After about 9-10 sessions, your deductible will be met
Remember: Other medical services you use also count toward your deductible, so it may be met sooner if you have other healthcare expenses.
If you've met part of your deductible, you may have a visit where part goes to the deductible and part triggers coinsurance.
Example:
- • Deductible: $1,500 (you've paid $1,400 so far)
- • Remaining deductible: $100
- • Session allowed amount: $160
- • $100 applies to finish deductible
- • $60 remaining × 20% coinsurance = $12
- • Total for this session: $112
This "split" scenario only happens once—the visit where your deductible is fully met. After that, you'll just pay coinsurance.
Once your deductible is met, you'll pay your coinsurance percentage (or copay, depending on your plan) for each session.
Example:
- • Deductible: Met ($1,500 paid)
- • Your coinsurance: 20%
- • Allowed amount: $160
- • You pay: $32 per session (20% of $160)
- • Insurance pays: $128 per session
This is typically the "sweet spot" for therapy—your deductible is met, so your per-session cost is much lower.
If you've reached your annual out-of-pocket maximum, insurance covers 100% of allowed amounts for the rest of the year. You pay nothing for covered services.
Example:
- • Out-of-pocket max: $4,000 (fully met)
- • Allowed amount: $160
- • You pay: $0
- • Insurance pays: $160 (100%)
This typically happens if you've had significant medical expenses during the year. Once you reach this point, maximize your care—your insurance covers everything.
Sometimes claims are denied or held pending additional information. Common reasons include:
- •Coverage not active: Your insurance wasn't active on the date of service
- •Prior authorization required: Some plans require pre-approval for therapy
- •Incorrect member ID: Information on the claim doesn't match insurance records
- •Coordination of benefits: If you have multiple insurance plans
- •Service not covered: The specific service isn't included in your plan
If a claim is denied, don't panic. We'll work with you and your insurance to resolve the issue. Many denials can be overturned with additional information or a correction.
Billing Timeline Expectations
When to expect documents and what to do if they don't arrive
| Document | Expected Timing | If You Haven't Received It |
|---|---|---|
| EOB from Insurance | 2-4 weeks after your appointment | Check your insurance portal online—many insurers post EOBs there before mailing. If nothing after 4 weeks, call your insurance. |
| Statement from Us | 3-6 weeks after your appointment | Contact our billing team. Your claim may still be processing, or there may be no balance due. |
| Denial Notice | 2-4 weeks if claim is denied | If your EOB shows a denial, contact us. We can help determine why and whether an appeal is appropriate. |
Why Timing Can Vary
- • Insurance companies have different processing speeds
- • Claims submitted near holidays may take longer
- • Complex claims or those requiring review take additional time
- • Mail delivery adds a few days to paper EOBs and statements
- • Coordination of benefits (multiple insurance plans) adds complexity
Questions About Your Bill
Who to contact and what information to have ready
Contact Our Billing Team When:
- •Your bill doesn't match your EOB
- •You think there's a coding error
- •You're being billed more than expected
- •You need a payment plan
- •You have questions about charges
- •You need an itemized statement
Contact Your Insurance When:
- •Your EOB seems incorrect
- •A claim was denied and you don't understand why
- •You want to appeal a denial
- •You need to verify your benefits or coverage
- •Your deductible/OOP max amounts seem wrong
- •You haven't received an EOB after 4+ weeks
Information to Have Ready When You Call
- Your insurance member ID number
- Date(s) of service in question
- Claim number (from EOB)
- Copy of your EOB
- Copy of your bill (if you have one)
- Notes about your specific question
Disputing a Charge
Your rights and how to resolve billing concerns
You have the right to question any charge on your bill. If you believe there's an error—whether it's a coding mistake, incorrect amount, or service you didn't receive—you can and should dispute it. Most billing issues are resolved quickly once identified.
Steps to Dispute a Charge
- 1
Gather your documentation
Collect your EOB, bill, and any notes about the service in question.
- 2
Contact our billing team first
Many issues are simple misunderstandings or easily corrected errors. We want to help resolve this.
- 3
Request an itemized statement if needed
You have the right to a detailed breakdown of all charges.
- 4
Contact your insurance if needed
If the issue is with how your insurance processed the claim, they need to be involved.
- 5
Document everything
Keep records of all calls (date, time, person's name, reference number) and correspondence.
Appeal Rights with Insurance
If your insurance denies a claim and you believe it should be covered, you have the right to appeal.
- • Internal appeal deadline: Usually 180 days from denial
- • External review available if internal appeal is denied
- • Expedited appeals available for urgent situations
Good Faith Estimate Disputes
If you received a Good Faith Estimate and your bill exceeds it by $400 or more for the same services:
- • You can dispute within 120 days of the bill
- • Use the Patient-Provider Dispute Resolution process
- • No Surprises Help Desk: 1-800-985-3059
Questions About Your Bill?
Billing can be confusing, and we're here to help. If you have questions about a charge, need an itemized statement, or want to discuss payment options, please reach out to our billing team.
Related Information
Understanding Your Costs
Learn about deductibles, copays, coinsurance, and out-of-pocket maximums
Verify Your Benefits
How to confirm your mental health coverage before starting therapy
Good Faith Estimate
Cost estimates for self-pay and uninsured patients
Insurance FAQ
Answers to common insurance and billing questions