By MATTHEW HOLT
I’ve decided to share a piece I previously posted on LinkedIn to ensure it remains accessible. My goal is to provide insights so you don’t have to navigate these complexities alone, and in the spirit of making Brett Jansen happy, I’m opting for single-line paragraphs.
The Confusion of Medical Billing
A pressing question arises: how do LabCorp, brown & Toland, and Blue Shield of California determine their billing practices?
A Personal Experience with Annual Checkups
- I attended my complimentary yearly health examination.
- This included blood tests that appear to be covered under the Affordable Care Act (ACA) as part of the free checkup.
- I remain in the pre-diabetic category; however, my cholesterol levels are satisfactory!
- The claim from Blue Shield of California is available on their website.The Explanation of Benefits (EOB) states:
– Total billed amount: $322.28
– In-network savings applied: $271.37
(noting a difference of $50.91)
– Patient’s financial responsibility: $0 - The breakdown includes five separate charges for various tests (which presumably add up to the total billed amount).Each test has its own price but all reflect an “in-network savings” equal to that same amount with patient responsibility listed as $0.
- LabCorp subsequently sends me a bill for $322.28 with “adjustments” totaling $287.34, leaving a balance due of $34.94.
- I reach out to customer service at Blue Shield of California only to encounter an infuriating automated system that reads back the EOB information already visible online.
- After several frustrating minutes navigating this system, I press ’0′ and finally connect with a representative after what feels like an eternity. After extensive hold time, she contacts Brown & Toland—the Independent Practice Association involved in this lab billing process—and they inform her that I owe them $35 (after 26 minutes on hold).
- I inquire why I’m being charged for lab tests when they should be complimentary under ACA guidelines; she explains that they received CPT codes from the medical group which indicate which specific lab tests incur charges.
Lack of Transparency in Billing Practices
- (The LabCorp invoice itemizes charges by test without providing codes; however, adjustments apply only at total level making it impossible to discern individual test adjustments—contrastingly noted on Blue Shield’s site where all amounts adjust downwards.)
- This crucial information was absent from whatever documentation was provided by the IPA representative during our call; thus she returns once more for clarification—yes, I can be persistent!
A Frustrating Resolution Process:
- At minute 45 into our conversation—a true marathon—the IPA representative joins us again asking if I’d prefer service or diagnosis codes while assuring me they’ll review my claim further. My suspicion is one or more codes may not qualify as preventative care under ACA standards since eventually she provides me with five CPT codes related to those tests.
- The Blue Shield rep remains on line throughout this ordeal and confirms alongside her counterpart from Brown & Toland—who seems likely based overseas given her accent—that my copay stands at $50 despite my bill reflecting just over thirty-four dollars.
(Interestingly enough both representatives struggle with poor phone connections.)