By MATTHEW HOLT
I’ve been on a quest to attempt to perceive why I’m being charged $34.95 by Labcorp for some lab assessments that I feel must be free beneath the ACA preventative care statutes, and for which my insurer Blue Protect of Californian has issued me an EOB with a $0 co-pay.
It’s been a microcosm of the chaos of American well being care to this point, If you wish to catch up right here’s half 1, half 2, half 3 and half 4
Chances are you’ll recall that I had paid a $50 co pay for the lab assessments linked to my preventative annual wellness go to in 2024 (and I didn’t concentrate) however that once I obtained a $34.94 cost from Labcorp in 2025 and located that Blue Protect stated my copay was $0, I made a decision to research.
I’ve had a variety of assist from Rhea, a senior customer support rep at Labcorp who I feel is having practically as a lot enjoyable with this as I’m. She advised me that the co-pay Labcorp tries to gather is the decrease of $50 or regardless of the whole invoice is. For the 5 assessments I had, Labcorp’s agreed fee with Brown and Toland Physicians (the Blue Protect-owned IPA that contracts with their HMO, of which I’m a member) was $34.94. So that’s the reply as to that cost.
However it nonetheless doesnt reply a pair extra questions.
- Why was a subsequent lab take a look at I had as a comply with up additionally proven by Blue Protect as a $0 copay on the EOB?
- Why weren’t the lab assessments I had thought of preventative beneath the ACA and subsequently additionally free?
Rhea’s guess for the primary reply is that Labcorp receives a capitated quantity for lab assessments from Blue Protect or Brown and Toland, and that the second take a look at was someway lined beneath that. Possibly, however then why wasn’t the primary one?
The second query takes me additional down a rabbit gap. Rhea dug out the order from One Medical to Labcorp. You may see beneath that the CPT codes are on it (what the assessments really are) and in addition what the associated prognosis codes are.
I in fact requested chatGPT what these prognosis codes have been and the reply is
E78.5 = Hyperlipidemia (i.e. excessive ldl cholesterol)
R73.03 = PreDiabetes
E66.811 = Weight problems class 1
M10.9 = Gout
As you would possibly suspect as a reasonably typical 60+ yr previous American, I match the invoice for all these diagnoses. The CPT codes for the assessments I had are full blood rely, Metabolic Panel, Hemoglobin (A1C), Lipid Panel, and Uric Acid (which causes gout).
Presumably all of these, with the doable exception of the Gout/Uric Acid, may very well be seen to be preventative. In spite of everything the CMS website explains that preventative screening is free for “Annual Wellness Visits and Bodily Exams, for example with a main care physician and Well being Screenings for blood strain, ldl cholesterol, blood sugar for diabetes, and numerous most cancers screenings akin to colonoscopies and mammograms”.
So why is that this not free to me? Rhea from Labcorp means that Blue Protect initially issued me a $0 copay EOB however later ought to have reprocessed that when it obtained the invoice from Labcorp, and advised me to pay the $39.94. She additionally discovered that along with CMS suggesting what must be referred to as preventative, Blue Protect of CA has a really lengthy doc with what it thinks is preventative care. You may see and obtain it right here.
I requested ChatGPT to learn it for me and after a little bit of wanting round we concluded that E78.5 is within the record of relevant ICD-10 diagnoses codes for Annual well being appraisal visits, that are a (free) lined service. So my excessive ldl cholesterol must be screened at no cost.
Then again there’s an entire part on Web page 28 of the doc discussing per-diabetes schooling but it surely doesn’t explicitly say that an A1C take a look at is roofed beneath the annual wellness go to. And for those who go manner down, to web page 116, there’s a desk that means that final yr a Blue Protect overview eliminated a number of of the diabetes codes, together with R73.03.
Now I’m not going to fake that I perceive what the hell is occurring on this doc, and why (or whether or not) Blue Protect is ready to change what CMS says it ought to do–if that’s what in truth is occurring. However it does appear bizarre.
And once more, as a result of there aren’t any precise prices per take a look at from Labcorp (there are prices per take a look at however they’re bundled and discounted on the invoice), it’s unattainable to inform what the contracted value for every take a look at was, and subsequently whether or not I obtained some at no cost (as I feel I ought to have) and what I used to be really charged for.
Lastly, I obtained very excited as Blue Protect despatched me a message tonight which had an attachment which I feel is a response to the grievance that was someway filed for me by somebody from their govt places of work partly 2. However the attachment wasn’t correctly formatted. So I don’t know what it says!
At least I’d anticipate on this journey.
However hopefully we’re near discovering out who’s charging whom for what and why!
Matthew Holt is the founder and writer of THCB
