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 exams that I feel ought to be free underneath 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 thus far, If you wish to catch up right here’s part 1, part 2, part 3 and part 4
You could recall that I had paid a $50 co pay for the lab exams linked 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 mentioned my copay was $0, I made a decision to research.
I’ve had numerous 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 complete invoice is. For the 5 exams I had, Labcorp’s agreed charge 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.
Nevertheless it 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 exams I had thought-about preventative underneath 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 exams from Blue Protect or Brown and Toland, and that the second check was by some means coated underneath 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’ll be able to see beneath that the CPT codes are on it (what the exams truly are) and likewise what the associated analysis codes are.
I after all requested chatGPT what these analysis codes had 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As you would possibly suspect as a fairly typical 60+ 12 months outdated American, I match the invoice for all these diagnoses. The CPT codes for the exams I had are full blood rely, 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 spite of everything the CMS web site explains that preventative screening is free for “Annual Wellness Visits and Bodily Exams, as an example with a major care physician and Well being Screenings for blood strain, ldl cholesterol, blood sugar for diabetes, and varied most cancers screenings similar 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 advised 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 can see and download it 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 at no cost.
However 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 check is roofed underneath the annual wellness go to. And in case you go approach down, to web page 116, there’s a desk that implies that final 12 months a Blue Protect evaluation 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 happening 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 actual fact is going on. Nevertheless it does appear bizarre.
And once more, as a result of there are not any precise prices per check from Labcorp (there are costs 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 at no cost (as I feel 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 feel is a response to the grievance that was by some means filed for me by somebody from their govt workplaces partly 2. However the attachment wasn’t correctly formatted. So I don’t know what it says!
A minimum of I’d count on 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
