Eliott Dear, Counsel — Out-of-Network Reimbursement Lawyer

An out-of-network underpayment does not announce itself. It sits in plain sight on the explanation of benefits, spread across a handful of columns that a busy front office tends to skim, post and file. Eliott Dear, counsel, starts every file on that page, because the EOB is the plan’s own written account of what it decided and why.

Billed: The Physician’s Number

The billed column carries the charge for each line of service as the practice submitted it. It is the one figure on the EOB the plan did not choose. Eliott Dear first checks that every billed line on the EOB matches the claim the office actually sent, because a dropped or bundled line throws off every comparison after it.

Allowed: Where the Cut Is Made

The allowed amount is what the plan decided the service was worth. For a physician with no contract with that plan, nothing negotiated stands behind this figure; the plan set it on its own. This is the column where an out-of-network underpayment is born. New York law names the FAIR Health 80th percentile as the benchmark, so Eliott Dear sets the allowed amount for each line beside that benchmark for the same service.

Paid and Patient Responsibility

The paid column is what the plan actually sent to the practice. Patient responsibility is the share the plan assigned to the patient through deductible, coinsurance or copay. In the ordinary case the two together account for the allowed amount. When they do not, or when a line carries a denial instead of a payment, Eliott Dear pulls that line out and reads it on its own rather than letting it vanish into a total.

What the Attorney Reads First

Before any column, Eliott Dear reads the top of the EOB: the plan name, the group and every clue to how the plan is funded. That decides the track. A fully insured New York plan goes to New York State IDR, which the Department of Financial Services administers; a self-funded plan sits outside the state process. Only once the plan is placed does the line-by-line comparison begin, with the operative note and the billed charges laid beside the EOB.

Send the EOB

A practice that suspects an EOB came back short can send that one claim for a free review. Eliott Dear reads it column by column and says plainly whether the numbers support a submission.