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 believe ought to 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 date, If you wish to catch up right here’s half 1, half 2, half 3 and half 4
You could recall that I had paid a $50 co pay for the lab assessments related to my preventative annual wellness go to in 2024 (and I didn’t listen) however that after I bought 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 lots of assist from Rhea, a senior customer support rep at Labcorp who I believe is having practically as a lot enjoyable with this as I’m. She informed me that the co-pay Labcorp tries to gather is the decrease of $50 or regardless of the complete 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.
But it surely nonetheless doesnt reply a pair extra questions.
- Why was a subsequent lab check 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 due to this fact 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 check was by some means coated 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 truly are) and in addition what the associated analysis codes are.
I in fact requested chatGPT what these analysis 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 fairly typical 60+ yr previous American, I match the invoice for all these diagnoses. The CPT codes for the assessments I had are full blood depend, Metabolic Panel, Hemoglobin (A1C), Lipid Panel, and Uric Acid (which causes gout).
Presumably all of these, with the potential exception of the Gout/Uric Acid, may very well be seen to be preventative. In any case the CMS web page explains that preventative screening is free for “Annual Wellness Visits and Bodily Examsas an example with a major care physician and Well being Screenings for blood stress, ldl cholesterol, blood sugar for diabetes, and numerous most cancers screenings equivalent 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 bought the invoice from Labcorp, and informed me to pay the $39.94. She additionally discovered that along with CMS suggesting what ought to 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 listing of relevant ICD-10 diagnoses codes for Annual well being appraisal visits, that are a (free) coated service. So my excessive ldl cholesterol ought to be screened without cost.
Alternatively there’s a complete part on Web page 28 of the doc discussing per-diabetes schooling but it surely doesn’t explicitly say that an A1C check is roofed beneath the annual wellness go to. And for those who go manner down, to web page 116, there’s a desk that implies that final yr a Blue Protect assessment eliminated a number of of the diabetes codes, together with R73.03.
Now I’m not going to faux 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 actually is occurring. But it surely does appear bizarre.
And once more, as a result of there aren’t any precise prices per check from Labcorp (there are fees per check however they’re bundled and discounted on the invoice), it’s unimaginable to inform what the contracted price for every check was, and due to this fact whether or not I bought some without cost (as I believe I ought to have) and what I used to be truly charged for.
Lastly, I bought very excited as Blue Protect despatched me a message tonight which had an attachment which I believe is a response to the grievance that was by some means filed for me by somebody from their government places of work partly 2. However the attachment wasn’t correctly formatted. So I don’t know what it says!
A minimum of 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
