Why Your Therapy Cost Is Different From Your Insurance Verification of Benefits
Before your visit, many healthcare providers check your insurance. This step is called a verification of benefits (VOB) or a cost estimate.
After your appointment, your provider sends the actual claim to your insurance. This is when your insurance performs adjudication — a formal review of the claim. They look at the exact services provided, apply your specific plan rules, and calculate the final payment and patient responsibility.
Here's why your VOB estimate may be different from what cost you're responsible for:
The Estimate Is Based on What the Insurance Reports, Not What They Ultimately Decide
Insurance companies often give general benefit information, but when they process the claim, they apply exact rules that may not have been visible to Octave (or any other medical service provider) during the VOB check - these include prior authorizations, referral requirements, and varying deductible or out of pocket costs being met.
Deductibles and Out-of-Pocket Balances Change
Your cost estimate may have been created before another medical expense hit your plan. If you had a prescription filled or visited another doctor, your deductible or out-of-pocket totals may have changed by the time the claim was processed.
Insurance Applies “Allowed Amounts”
Your provider may bill one amount, but insurance may only pay based on a contracted rate. During adjudication, the insurer adjusts the claim to this allowed amount, which can change the portion you are responsible for.
Insurance Sometimes Add or Remove Coverage Requirements
During processing, your plan may decide a service needs prior authorization, applies a visit limit, or categorizes the service differently than expected.
What Is a Verification of Benefits or Cost Estimate?
Before your visit, many healthcare providers check your insurance. This step is called a verification of benefits (VOB) or a cost estimate.
Think of it as a preview of what your insurance coverage looks like. Your provider contacts your insurance company to confirm:
- Whether your plan is active
- What services are covered
- Your copay, deductible, or coinsurance
- Whether you need prior authorization
Using this information, your provider gives you an estimate of what you may owe. It’s the best guess based on the information the insurance company provides at that moment.
What Does This Mean for You?
- A VOB or cost estimate is not a final bill — it’s a snapshot based on the information available at the time.
- The final amount you owe only becomes clear after your insurance finishes processing the claim.
- If the final amount is different, it doesn’t necessarily mean anything was done incorrectly — it simply reflects your plan’s rules and your benefits at the time the claim was processed.
If You Ever Have Questions: You should always feel comfortable asking your provider’s billing team or your insurance company for help. They can explain the estimate you received, the processed claim, and any differences between the two.
