Behind the Bill: Where Your Health Care Dollars Go

If you've ever wondered why your health insurance company sends you an Explanation of Benefits, the difference between a copay and coinsurance, or why you get multiple bills for the same doctor's visit, you're not alone.

While health care, medical bills, and health insurance can be complex and difficult to navigate, BJC HealthCare provides resources and support to help patients better understand their options.

Here is the step-by-step journey of a medical bill from start to finish: What happens after your appointment, how insurance and health care providers work together to process the care received, and where to go for financial support with medical bills.  

Medical billing is made up of many steps that happen behind the scenes. When patients understand the process, it may help them feel more empowered, confident, and prepared when the bill arrives.

Key terms

Health insurance has a lot of terminology, and by understanding a few key concepts, you can make it easier to estimate costs and avoid financial surprises.  

Premium: The amount you pay each month to maintain your health insurance coverage, whether or not you use medical services.

In-network: Providers who have agreements with your insurance company to offer care at negotiated rates.  

Out-of-network: Providers who are not within your insurance company’s coverage network, and therefore do not have negotiated rates, which may lead to higher out-of-pocket costs for you.  

Copay: The fixed cost you will pay to an in-network provider for specific services, like a primary care visit. Copays are determined by your health insurance company.

Deductible: The amount you pay toward health care services before your insurance begins to share the cost with you. Deductibles are determined by your health insurance company.

Coinsurance: Your share of the cost for covered health care services after you've met your deductible. Instead of paying a fixed dollar amount, you pay a percentage of the cost. For example, if your plan has 20% coinsurance, you'll pay 20% of the covered service cost and your insurance will pay the remaining 80%. Coinsurance payments count toward your out-of-pocket maximum.

Out-of-pocket maximum: The most you'll pay for covered health care services during a plan year. Once you reach this limit through deductibles, copays, and coinsurance, your health plan generally pays 100% of covered costs for the rest of the year.

Reviewing health care insurance documents is not riveting. However, spending one hour going over your documents at the start of each new enrollment period is a good way to stay ahead of your financial health. Make a note in your budget of the amount of your deductible and expected copay costs.  

If needed, there are resources available to find help paying for medical bills and prescriptions.

The life cycle of a bill  

Your provider submits a medical claim.  

After a visit, procedure, or hospital stay, your health care provider submits a claim to your insurance company.  

This claim includes details about the services you received, along with standardized billing and diagnosis codes.  

Insurance diagnosis codes are part of the International Classification of Diseases (ICD) system. It provides a standardized way to describe diseases, injuries, symptoms, and other health conditions. In the United States, the ICD-10-CM (Clinical Modification) is the primary system used for medical claims. These codes are essential for establishing medical necessity, processing insurance claims, and ensuring accurate reimbursement. The ICD-10-CM code set contains nearly 70,000 diagnosis codes.

Your insurance processes the claim. 

Each claim undergoes a review process before payment is issued by your insurance. During this review, your insurance company verifies eligibility, applies your benefits, confirms network status (in-network versus out-of-network), and determines whether deductibles, copays, or coinsurance apply. The processing of the claim may take up to several weeks or months.  

Your insurance sends you an Explanation of Benefits.  

An Explanation of Benefits (EOB) is not a bill. It's a statement from your insurance company that explains how a claim was processed, including the services provided, the amount billed, any provider discounts, what your insurance paid, and what you may owe.

An EOB can help you anticipate upcoming medical bills. You should next receive a bill from your provider for the amount due. The bill from your provider may take longer to receive. If you received care from multiple providers or facilities, you may receive more than one bill.

Your provider bills you.

Review the dates of service, provider names, and amounts owed to make sure the charges match the care. If something seems wrong, contact your insurance company or the provider’s billing department for clarification. You should wait to pay until after you get the actual bill, not the EOB.

Receiving multiple bills at once for the same care experience can be surprising, confusing, and even stressful. You may receive different bills for the same treatment because different providers may bill separately for their services. For instance, a hospital, physician, laboratory, or radiologist may each submit their own claim and send their own statement after insurance processing.  

Patient responsibility refers to the portion of health care costs that aren’t covered by your insurance plan. This amount can include deductibles, copayments, coinsurance, and services not included in your benefits. By reviewing your EOB and provider statements, you can get a better sense of how the amount you owe was calculated.  

Health care bills may seem complex and confusing, but every bill reflects a series of steps involving insurance companies, providers, coders, and payment systems. By understanding the process, you will be more empowered to review bills with confidence, ask informed questions, and manage health care expenses proactively.  

Options for financial assistance  

At BJC HealthCare, patients without insurance will automatically receive a 40% discount on the billed charges. Many health care organizations, including BJC HealthCare, also offer interest-free payment plans. There are financial assistance programs for people who need them, too.  

The Financial Assistance Policy for BJC HealthCare helps eligible patients receive free or discounted care. BJC HealthCare aims to help patients who cannot afford care. To receive financial assistance, you will be asked to complete a financial assistance application and provide income verification per the Financial Assistance policy such as pay stubs, W2s, or tax returns. Please refer to the Financial Assistance Policy for more information on how to apply.

If you have questions about your coverage, it’s best to contact your insurance company first. For additional assistance, patients can also call 314-362-8400 or toll-free 855-362-8400 to speak with a representative. And the Billing and Financial Assistance page is also a helpful resource on the BJC website.  

The most frequently asked questions billing specialists receive

“Why did I get more than one bill?"

Multiple bills for the same visit may be the result of different providers billing separately for the services they performed.  

"Why am I getting a bill months later?"

The time between receiving care and receiving a bill is often due to insurance claim processing. Providers typically wait for the insurance company to review the claim and determine your patient responsibility before sending a final bill.

"Why does health care use so many codes?"

Health care codes create a standardized language that allows providers, hospitals, insurance companies, and government programs to communicate consistently about diagnoses, procedures, and services. Because there are thousands of medical conditions, treatments, and circumstances that can affect a patient's care, many codes are needed to document what happened during a visit and ensure claims are processed correctly.  

Questions about your bill?  

If something doesn’t look right, or you simply need help understanding a bill, get in touch with your provider’s billing team. They can help explain charges, insurance adjustments, payment options, and options for financial assistance. If you have questions about your insurance plan benefits, contact your insurance company for additional assistance.

Check out our Billing and Financial Assistance information to learn more.