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Labcorp, Blue Shield and my $34.95 co pay (part 5)

By MATTHEW HOLT

I have been on a quest to try to understand why I am being charged $34.95 by Labcorp for some lab tests that I think should be free under the ACA preventative care statutes, and for which my insurer Blue Shield of Californian has issued me an EOB with a $0 co-pay.

It’s been a microcosm of the chaos of American health care so far, If you want to catch up here’s part 1, part 2, part 3 and part 4

You may recall that I had paid a $50 co pay for the lab tests connected to my preventative annual wellness visit in 2024 (and I didn’t pay attention) but that when I got a $34.94 charge from Labcorp in 2025 and found that Blue Shield said my copay was $0, I decided to investigate.

I have had a lot of help from Rhea, a senior customer service rep at Labcorp who I think is having nearly as much fun with this as I am. She told me that the co-pay Labcorp tries to collect is the lower of $50 or whatever the total bill is. For the 5 tests I had, Labcorp’s agreed rate with Brown and Toland Physicians (the Blue Shield-owned IPA that contracts with their HMO, of which I am a member) was $34.94. So that is the answer as to that charge.

But it still doesnt answer a couple more questions.

  1. Why was a subsequent lab test I had as a follow up also shown by Blue Shield as a $0 copay on the EOB?
  2. Why weren’t the lab tests I had considered preventative under the ACA and therefore also free?

Rhea’s guess for the first answer is that Labcorp receives a capitated amount for lab tests from Blue Shield or Brown and Toland, and that the second test was somehow covered under that. Maybe, but then why wasn’t the first one?

The second question takes me further down a rabbit hole. Rhea dug out the order from One Medical to Labcorp. You can see below that the CPT codes are on it (what the tests actually are) and also what the related diagnosis codes are.

I of course asked chatGPT what those diagnosis codes were and the answer is
E78.5 = Hyperlipidemia (i.e. high cholesterol)
R73.03 = PreDiabetes
E66.811 = Obesity class 1
M10.9 = Gout

As you might suspect as a pretty typical 60+ year old American, I fit the bill for all those diagnoses. The CPT codes for the tests I had are complete blood count, Metabolic Panel, Hemoglobin (A1C), Lipid Panel, and Uric Acid (which causes gout).

Presumably all of those, with the possible exception of the Gout/Uric Acid, could be seen to be preventative. After all the CMS web site explains that preventative screening is free for “Annual Wellness Visits and Physical Exams, for instance with a primary care doctor and Health Screenings for blood pressure, cholesterol, blood sugar for diabetes, and various cancer screenings such as colonoscopies and mammograms”.

So why is this not free to me? Rhea from Labcorp suggests that Blue Shield initially issued me a $0 copay EOB but later should have reprocessed that when it got the bill from Labcorp, and told me to pay the $39.94. She also found that in addition to CMS suggesting what should be called preventative, Blue Shield of CA has a very long document with what it thinks is preventative care. You can see and download it here.

I asked ChatGPT to read it for me and after a bit of looking around we (that’s me and ChatGPT) concluded that E78.5 is in the list of applicable ICD-10 diagnoses codes for Annual health appraisal visits, which are a (free) covered service. So my high cholesterol should be screened for free.

On the other hand there’s a whole section on Page 28 of the document discussing pre-diabetes education but it doesn’t explicitly say that an A1C test is covered under the annual wellness visit. And if you go way down, to page 116, there’s a table that suggests that last year a Blue Shield review removed several of the diabetes codes, including R73.03.

Now I am not going to pretend that I understand what the hell is going on in this document, and why (or whether) Blue Shield is able to change what CMS says it should do–if that is what in fact is happening. But it does seem weird.

And again, because there are no actual costs per test from Labcorp (there are charges per test but they are bundled and discounted on the bill), it’s impossible to tell what the contracted cost for each test was, and therefore whether I got some for free (as I think I should have) and what I was actually charged for.

Finally, I got very excited as Blue Shield sent me a message tonight which had an attachment which I think is a response to the grievance that was somehow filed for me by someone from their executive offices in part 2. But the attachment wasn’t properly formatted. So I don’t know what it says!

No less than I’d expect on this adventure.

But hopefully we are close to finding out who is charging whom for what and why!

UPDATE. I called Blue Shield’s grievance line and a nice customer service rep read me the letter that I couldn’t see online. Essentially Blue Shield has asked Brown and Toland to explain what happened. That grievance will take another 30 days! The rep wasn’t able to send it to me in my portal, but she could send me an email (It will be one of those secured ones that are super annoying to open). She told me it was sent while she was on the phone but 30 mins later, it’s not here!

Matthew Holt is the founder and publisher of THCB

How come I owe Labcorp $34.94? (Part 4)

By MATTHEW HOLT

For those of you waiting for the Labcorp, Blue Shield of California, Brown & Toland Physicians Physicians update, the ball has been moved a couple of years down the field.

If you want to catch up here is part 1, part 2 and part 3.

You’ll recall we left it with a mystery $34.94 bill which didn’t either fit the official $50 copay amount I have, nor the $0 patient responsibility in my EOB. I got a call from Rhea Fleming, an experienced customer rep at Labcorp, on whose virtual desk this has been dumped. We had a lovely conversation in which we agreed that the co-pay should either have been $50 or $0 but that it’s possible that the co-pay is the lower of $50 or the amount Labcorp was trying to collect.

She had previously called the Blue Shield of California provider line to try to figure this out. Blue Shield had indeed kicked this claim from Labcorp to Brown and Toland the IPA I am assigned to in the HMO product I bought. The charges from Labcorp were $322.28 and the response from B&T was that the contractual price (i.e. what they agreed to pay Labcorp for those tests) was $34.94, hence the “adjustment” of $287.34. However in Labcorp’s system the algorithm interpreted B&T’s response as saying 1) the agreed payment is the $34.94 according to the contract and 2) they were not going to pay so the patient owes the difference. When Rhea Fleming asked Blue Shield’s rep why the patient owed payment on this, the Blue Shield rep said that the procedure code and diagnosis code from my PCP (One Medical) did not count as preventative care. In other words Labcorp has not got paid at all for running these tests so far, because they are according to B&T “not preventative”. Although IMHO, CMS says that they are. And of course as it says my copay is $0 I’m interpreting Blue Shield of California’s EOB as saying that to me!

Hence Labcorp generated the bill for the $34.94 and sent it to me. Which started this whole telenovela.

BTW Rhea’s conclusion was that as none of the tests were “preventative,” Labcorp billed me the $34.94 as that was the total it was contractually owed rather than the $50 copay I am supposed to pay for lab work. I actually checked back in my Labcorp account and found that last year I did in fact pay $50 so perhaps last year I had different tests or somehow they have changed the algorithm. I checked the EOB for that 2024 bill and the total charge was $445.20 of which Blue Shield paid $28.07. No I couldn’t find the Labcorp bill on their system, presumably because I have paid it! Given that I paid $50 for services from Labcorp on that date (yes, it took me 7 months to pay up!), it’s likely that the agreed payment was $78.07 ($50+$28.07) of which I unthinkingly paid the $50 copay. And yes that should have been preventative too. (Perhaps I should ask for that $50 back!!)


BRIEF UPDATE: Rhea from Labcorp looked into this 2024 bill and that is exactly what happened

Then, I had another thought.

It turns out that the lab results this year generated a further concern in my doctor’s mind. (Bear in mind I had the lab tests before the office visit so that we could discuss the results). It seems that my iron levels were a little low, so while I was in the doctor’s office he ordered some more tests specifically about that. As One Medical has techs on site they drew my blood then and there and shipped it to Labcorp.

According to my EOB, Labcorp’s charge for those new tests was $60.79 of which Blue Shield or rather Brown and Toland again paid $0 and created an EOB which again said my patient responsibility was $0. I asked Rhea to check that bill in her system and it turns out that I do NOT owe Labcorp anything on that set of tests. Maybe they were coded as preventative? I tried to find the bill on my patient portal at Labcorp but because I don’t owe anything I haven’t been sent an invoice and without an invoice number you cannot check the bill!

When Rhea ended the call with me, her next move was going to enquire of Blue Shield and Brown and Toland what the reason was for me owing $0 on that bill! 

Meanwhile I await the result of the official Blue Shield investigation with interest. Of course this might just have come down to Amazon One Medical coding the tests incorrectly. But it’s all fun and games if you have unlimited patience in American health care.

And of course, this still isn’t over!

Hunting down my $34.94 lab test. An journey into the bowels of insurance billing (part 3)

By MATTHEW HOLT

So I am back dealing with Labcorp & Blue Shield of California over the mysterious $34.94 copay. If you want to catch up go here

Over the weekend Labcorp sent me a final due notice on my bill…. the one that they couldn’t tell me about without asking for all the information they already had.

I call Labcorp customer service in the Philipinnes. The friendly rep says that they have had a message saying that “the insurance company requires that Labcorp provides documentation from the ordering physician”. What documentation, I ask? A letter that tells them what the updated codes are. Given that the Brown & Toland Physicians rep told me those codes and they must have been sent them by Labcorp when Labcorp sent in the claim, that seems to make no sense. I’m not yet prepared to ask my doctor’s office to get involved in this! (Better look out though, Andrew Diamond!). So I’ll let that go for a moment.

However, Labcorp says that they received an EOB from Blue Shield of California PPO–it had my correct member number even though I am an HMO not PPO member. No the EOB did not come from the IPA Brown & Toland Physicians, and yes I asked very precisely. The EOB says the co-pay is $34.94. Labcorp can’t ascribe it to any one of the 5 individual lab tests (which all look preventative under the ACA to me but maybe one isn’t). So the $34.94 is the copay from the EOB that Blue Shield of California sent to Labcorp.

They asked me for my copy of the EOB. I sent one 5 days ago, but sent it again just to be sure.

Next up, asking Blue Shield of California what precisely they sent to Labcorp saying my co-pay is $34.94 when the one they sent me (well have on their website) says $0. Oh and by the way, the standard copay for labs on my plan is $50, not $34.94!

On my Blue Shield of California member portal there’s a message with a letter. Apparently they opened a customer grievance for me! I called the customer grievance number in the letter. According the answering IVR message there is a chat option for providers with grievances, but not one for consumers. My hold time is estimated at 20 minutes. A nice rep called Susie comes on in only 15 mins.

After verifying that she knows who I am she says there are 2 different grievances! One is an appeal for the lab test & one is a complaint about the process, both opened August 12. I suspect they were initiated by the nice man from the Executive office who called me on that day. Rep Susie is limited to telling me that appeal status. But she tells me that an appeal coordinator is looking into the complaint and will be back in touch within 30 days. AND she gives me an email to reach said coordinator at! So I sent that person an email….lets see what happens!

Matthew Holt is the founder and publisher of THCB

When is Preventative Care not Preventative? Let’s get Labcorp to join in! (Part 2) (with UPDATE)

By MATTHEW HOLT

To join in the fun I am having with Blue Shield of California & Brown & Toland Physicians IPA being unable to tell me why I have a $34.94 bill for lab work (see image) that should either be covered as preventable under the ACA, or have co-pay of $50 (see image of the BS of CA screenshot for the $50), I called Labcorp.

After 6 minutes I got a very confused person. BTW there is NO way to communicate with Labcorp on the website, and if you put your invoice number into their IVR system there is NO way to get a human. The only way to do that is to hang up and start again, NOT put in your invoice number and hit 0. Then wait on hold with muzak to get a human. They then ask your DOB and phone number. The call center is in the Philippines BTW.

I explained that I wanted information on which test was not covered under the ACA. Brown and Toland/Blue Shield’s EOB says I have a $0 co-pay (see image).

The Labcorp rep told me that of the 5 tests done (with CPT code and price), 3 were not covered. The Lipid (85027 $107.10), the A1C (80061 – $81.90) Uric Acid (84550 $43.05). 2 of those 3 clearly are covered under the ACA. The Uric Acid one may not be according to my reading of the CMS site. Labcorp submitted that bill to Blue Shield. The rep consistently told me the claim was sent to Blue Cross Blue Shield of CA, which doesn’t exist.



At that point — 15 minutes in — the call dropped. I don’t know if they just hung up but they had asked for my phone number. They didn’t call me back.

But I am a pain in the ass, and I called them back. After roughly 4 mins on hold, I got another rep. She told me ALL of the CPT codes/lab tests were subject to copay. She told me that Blue Shield (NOT Brown & Toland Physicians) has bundled all of these codes and there is a co pay for all of them. Which is what the bill says.

So the only thing I can do is to send an email with the screenshot of the EOB, which is from the IPA not Blue Shield. So I did that and may get a response in 3-5 business days.

I know you are on tenterhooks. Let’s see what happens next but the complete absence of anything resembling consumer transparency or access to the relevant information makes a mockery of everything Paul Markovich says on stage.

UPDATE. Labcorp both emailed me back AND asked me to contact them on Linkedin. See what they asked for! Yes even though they have sent me a bill and I sent them the invoice number, they want every detail possible about the claim they ALREADY have!

Full email below just for giggles

Oh and when I went to DM them on Linkedin as they requested their account was not accepting DMs!

2nd UPDATE: A very nice man from the Blue Shield of California corporate office called me up. We discussed whether the care I got was preventative or not and why I was being charged the $34.94. Of course he didn’t know. He agreed with me that it was a shit show, and actually started to complain that sometime HE had been charged for preventative stuff he thought should have been free.. He didn’t have any solution other than calling Brown and Toland to cancel the charge, but I told him I didn’t want any special treatment (at least not yet!).  I told him I wanted no special favors, but I wanted the claim reprocessed and an explanation.

And there’s a part 3!

Matthew Holt is the founder and publisher of THCB

How exactly is my lab test co-pay $34.94?

By MATTHEW HOLT

I moved over something I wrote on linkedin, so that it doesn’t vanish. I do this type of thing so you don’t have to & to make Brett Jansen happy I am writing in one line paragraphs.

My question, is how do LabCorp, Brown & Toland and Blue Shield Of California come up with this stuff?

1. I go for my free annual checkup

2. I get blood/lab tests which AFAICT are included in the ACA free checkup.

3. My pre-diabetes is still “pre”. My cholesterol is good!

4. Blue Shield of California puts the claim on its website. The EOB representation says
–total billed $322.28
–In network savings $271.37
(note difference is $50.91)
–Patient responsibility $0

5. Then it has 5 sub-charges for different tests (which I assume total to the $322.28). All have a different price. All say “in network savings” of the same amount. All say Patient Responsibility $0

6. Labcorp sends me a bill. For $322.28. “Adjustments” $287.34. Difference $34.94.

7. I call Blue Shield of California customer service. Its annoying as hell automated system reads me the claim EOB that I can see on the website.

8. After a few minutes of that I hit 0 and get a human eventually. After a loooong time she goes to call Brown and Toland, the IPA that is somehow involved in the lab billing. They tell her that I do indeed owe $35. (26 mins on the call)

9. I ask her why, given they are allegedly free under the ACA, I am being charged for these lab tests. She says that the medical group has sent her the CPT codes and she can tell me which of the 5 lab tests I owe for.

10. (On the Labcorp bill the charges are split up by test [no codes provided], but the “adjustment” is to the total, so there’s no way to tell what the adjustment per test is. Reminder that on the BS site, they all adjust to $0.)

11. But that information is not in whatever documentation the IPA gave her. She goes back to call them AGAIN. Because, yes I am difficult and I did ask her to. Minute 37 at this stage

12. Minute 45. The person from the IPA comes on line. She keeps asking if I want a service or a diagnosis code. But tells me they will review the claim. My guess is that one of these codes doesn’t count as preventative. Eventually she gave me the 5 CPT codes for the tests.

13. The BS rep is still on the call. She chimes in and the IPA rep (who I think is in India judging by accent and bad phone connection) agrees that my lab copay is $50. (BTW the BS rep is clearly American but her phone connection is dreadful too!)

14. After a lot of clarification (OK, me leading the witnesses) they both agree that if the co-pay is $50 but my bill is $34.94, then something is off, and maybe one of the codes has been classified as non-preventative, therefore not free under the ACA.

15 The IPA (Brown & Toland Physicians) rep is going to resubmit this to the claims team. I should get a new EOB. From whom I have no idea. I thank them both for their time and we hang up. 1 hour 4 minutes

I know that wasted more than $34.94 of my time, and certainly way more than that of Blue Shield of California & Brown & Toland Physicians money. But it’s just an indication of how screwed up internal billing and customer service is at these antique orgs!

If you want to follow along, there’s a part 2!

Matthew Holt is the founder, author and publisher of THCB

Pamela Stahl, Avalon Healthcare Solutions

Pamela Stahl is the President of Avalon Healthcare Solutions. You’ve heard of pharmacy benefits managers (PBMs) but Avalon is a labs benefits management company. Working on behalf of health insurers Avalon ensures that patients are getting the right labs at the right price, . Why are they needed? There are 14 billion lab tests and they drive a lot of health care decisions (70%+!). As you might guess there’s a ton of variation in test price, lots of test are ordered in error, many are repeated, and many are unnecessary. Avalon’s job is to figure that all out!–Matthew Holt 

#Healthin2Point00, Episode 228 | Mahana, Vera, Cadence, Commure & Ovia

#HealthIn2Point00 is still catching up on back deals from my HIMSS “vacation” when Jess lost track of me. Mahana Therapeutics gets $61m for its IBS related CBT DTx. Not everyone is happy! Vera Whole Health Clinic gets $50mm even if they don’t love Jess! Cadence gets $41m for RPM. Commure buys PatientKeeper from HCA, and LabCorp buys femtech co Ovia Health–Matthew Holt

Suit Says Test Labs Cheat Medicare, Medicaid

By MERRILL GOOZNER

Despite recent court settlements that recouped more than a quarter billion dollars from lab-test companies for allegedly overbilling California’s Medicaid program, the federal government seems to be ignoring similar schemes that drain Medicare coffers.

The cases involve the nation’s two largest medical laboratory-testing companies – Laboratory Corporation of America and Quest Diagnostics – that together control about half the annual $25 billion lab test market. The Medicare suits, filed in federal court in Manhattan by a former industry executive, claim the testing companies charged insurers like UnitedHealthcare unprofitably low rates while squeezing Medicare and Medicaid.

The whistleblower suits allege the schemes relied on sweetheart deals in which managed-care companies required in-network physicians to send their patients’ lab tests to a single testing company. As part of the deal for below-cost prices, the insurance companies allegedly promised to encourage physicians in their networks also to send Medicare and Medicaid patients to the same testing company, which then billed the Centers for Medicare and Medicaid Services (the federal agency that oversees both programs) or state Medicaid agencies at significantly higher rates.

Continue reading…