By Matthew Holt

I’m on a search to attempt to perceive why I’m charged $ 34.95 by Labcorp for some laboratory checks that I believe must be free underneath the ACA prevention care statutes, and for which my insurer Blue Defend of Californier has issued an EOB with a Co-Pay of $ 0.

Up to now it has been a microcosm of the chaos of American well being care, if you wish to catch up, right here is an element 1, half 2, half 3 and half 4

You may keep in mind that I had paid a CO of $ 50 for the laboratory checks associated to my preventive annual wellness go to in 2024 (and I didn't listen) however that once I acquired a value of $ 34.94 from Labcorp in 2025 and found that Blue Defend mentioned to look at that I used to be.

I’ve had a number of assist from Rhea, a senior customer support consultant at Labcorp that I believe is nearly as a lot happy with this as I do. She instructed me that the Co-Pay Labcorp is attempting to gather, the decrease of $ 50 is or regardless of the whole invoice is. For the 5 checks I had, Labcorp's agreed fee with Brown and Toland Articians (the Blue Defend possession IPA who contract with their HMO, of which I’m a member) was $ 34.94. So that’s the reply to that indictment.

However it nonetheless doesn't reply just a few extra questions.

1. Why was the subsequent laboratory check that I had as a comply with -up additionally proven by Blue Defend as a $ 0 copay on the EOB?
2. Why have been the laboratory checks that I had thought-about preventive underneath the ACA and subsequently additionally free?

RHEA GOK Earlier than the primary reply is that Labcorp receives a capitated amount for laboratory checks from Blue Defend of Brown and Toland, and that the second check was someway lined beneath. Perhaps, however why wasn't the primary?

The second query brings me additional in a rabbit gap. Rhea has excavated the order from one medical to Labcorp. Beneath you may see that the CPT codes are on it (what the checks are literally) and in addition what the associated analysis codes are.

In fact I requested chatgpt what these analysis codes have been and the reply is
E78.5 = hyperlipidemia (ie excessive ldl cholesterol)
R73.03 = Prediabetes
E66.811 = Weight problems class 1
M10.9 = gout

As you could suspect as a reasonably typical 60+ yr outdated American, I match the invoice for all these diagnoses. The CPT codes for the checks I had are full blood rely, metabolic panel, hemoglobin (A1c), lipid panel and uric acid (which causes gout).

Presumably, with the attainable exception of the gout/uric acid, all these could possibly be thought-about preventive. The CMS web site lastly explains that preventive screening is free for “Annual wellness visits and bodily examsFor instance with a physician for major care and Well being Screenings For blood strain, ldl cholesterol, blood sugar for diabetes and varied screens of most cancers comparable to colonoscopies and mammograms ”.

So why is that this not free for me? Rhea van Labcorp means that Blue Defend initially spent me a $ 0 copay EOB, but it surely ought to have been processed later that when it bought the Babcorp invoice, and instructed me that I needed to pay the $ 39.94. She additionally found that along with CMS suggests what a preventive one must be known as, Blue Defend or Ca has a really lengthy doc with what It thinks it’s preventive care. You possibly can see and obtain it right here.

I requested chatgpt to learn it for me and after trying round a bit, we concluded that E78.5 is within the listing with relevant ICD-10 analysis codes for annual visits to well being care, that are a (free) lined service. So my excessive ldl cholesterol have to be screened at no cost.

However, there’s a entire part on web page 28 of the doc about per diabetes training, but it surely doesn’t explicitly say that an A1C check falls underneath the annual wellness go to. And when you go far down, to web page 116, there’s a desk that implies that final yr a Blue Defend overview has eliminated a number of of the diabetes codes, together with R73.03.

Now I’m not going to fake to know what’s the hell is occurring on this doc, and why (or that) Blue Defend is ready to change what CMS says it ought to do – if that truly occurs. However it appears unusual.

And once more, as a result of there are not any precise prices per check of Labcorp (there are prices per check, however they’re bundled and discounted on the invoice), it’s inconceivable to say what the contracted prices have been for every check, and subsequently whether or not I acquired one thing at no cost (as I believe I ought to) and what I used to be really loaded for.

Finally I used to be very excited when Blue Defend despatched me a message tonight with an appendix that I believe is a response to the grievance that was someway requested by somebody from their government places of work partly 2. However the attachment was not made appropriately. So I don't know what it says!

At least I might anticipate on this journey.

However hopefully we will likely be near discovering out who for what and why!

Matthew Holt is the founder and writer of THCB