By MATTHEW HOLT
Extra tales of the woes of coping with medical insurance. I stay in Marin County, California and one of many issues that comes with that could be a analysis of ADHD for my kids. (OK, I’ve made that joke earlier than however it’s true!). My children now go to a psychiatrist for extra subtle med administration than they obtain at their pediatrician. We had been (till just lately) on a Blue Defend HMO by way of the Lined California trade.
Whereas I used to be on the physician’s workplace, I talked to the workers. They advised me I owed a $50 copay. I didn’t pay them (but) and I went on-line and noticed the declare
The cheap, knowledgeable shopper would possibly assume that I owed nothing. The clue being that
“Affected person Duty” was $0.
However in case you click on the “See Extra” within the high proper it exhibits you this
You in all probability nonetheless assume that I owe $0. However in case you add the numbers on the precise you would possibly discover they don’t whole $0.
Simply to ensure I am going to the advantages part of the web site. After I click on on “Psychological Well being & Substance Use Dysfunction”, the highest part is “Behavioral Well being Remedy”. There’s a alternative of “in residence” or “In workplace”. This specific session was by telehealth however as I assume that’s in workplace and I’ve additionally had some in workplace visits that seemed the identical, so I picked that. And there’s a $0 copay.
So now the cheap shopper sees a Affected person Duty that’s $0 and a $0 copay
However I’m not cheap. So I click on by to the EOB and see that there’s a distinction between what’s allowed and what Blue Defend paid.
On the EOB it exhibits a $0 affected person duty however a $50 co-pay/co-insurance cost. Which makes the $635 Blue Defend paid whole the $685 they’ve (very badly) negotiated with UCSF. And sure additionally they allow you to see the PDF of the unique EOB
That is the Schrodinger’s EOB as a result of I owe $0 and $50 on the similar time.
At this stage I name Blue Defend. No, they don’t have a chatbot or a human chat operate. It’s cellphone or nothing. Sure, it’s practically June 2026.
After speaking to their voice recognition system which nonetheless can’t acknowledge my birthdate or a lot else about me I finally hit 0 sufficient occasions to get by to their barely audible customer support rep within the Philippines. There are a number of echoes and we will’t hear one another. The rep calls me again. It nonetheless is echoing horribly. Ultimately she provides up and decides I want to talk to psychological well being customer support as this can be a behavioral well being declare. Though it’s an workplace go to that appears like some other declare to me.
She places me by. The voice recognition system solutions once more. After all I needed to inform all of it my info once more. It nonetheless can’t perceive me and I hit 0 a couple of extra occasions. Ultimately I get an American-based rep working within the psychological well being claims group. Not one of the info I advised the voice system transferred to the rep – even the bits I assumed it did perceive!
The rep advised me that I owed $50.
So why was it exhibiting me that I had $0 affected person duty? As a result of of their thoughts/system I had already paid the $50 on the time of service, subsequently it wasn’t my duty to pay it as I already had paid it. Though I hadn’t! (BTW it was a telehealth go to with no method to pay however no matter).
However I did owe the $50 co-pay
So subsequent I identified that the advantages on the web site stated there was a $0 co-pay. A-ha!
In reality in case you learn down within the positive print it says this
The rep advised me that the $0 co-pay was for workplace primarily based “therapy”. Had I scrolled down additional I might have discovered the outpatient go to class. That does have a $50 co-pay. So I scroll down and he or she is right.
However what distinguishes workplace primarily based therapy from an workplace go to? The place is that within the positive print? In reality the positive print for each “therapy” and “outpatient” are precisely the identical and by no means mentions what the distinction is.
I requested the rep. Remedy, she advised me, is particularly therapy for pervasive developmental dysfunction or autism. “Outpatient workplace go to” features a entire vary of analysis and in workplace remedies that she learn off to me. I believe that implies that CPT code 90792, which is the one billed on the EOB, triggers “outpatient workplace go to” not “therapy”. Though a part of this session clearly is therapy!
CPT Code 90792 is utilized by psychiatrists, psychiatric nurse practitioners, and different medical professionals to invoice for a Psychiatric Diagnostic Analysis with Medical Companies. It features a complete diagnostic evaluation, medical historical past, psychological standing examination, and doubtlessly medical decision-making for treatment administration
I believe that the “therapy” class within the Blue Defend’s advantages listing with the $0 co-pay is for CPT CPT codes (97151–97158) that are primarily used for Utilized Habits Evaluation for conduct remedy for kids with autism.
However who is aware of? They don’t inform you. They make it virtually not possible to search out out. And the EOB’s that Blue Defend problem have such shoddy UX it’s unlikely anybody understands what they need to be paying.
It’s 2026 and whereas we have now AI coming by the wazoo in our actual lives, this main well being plan simply doesn’t appear to care about its buyer’s expertise.
And naturally who however me would trouble going by all this crap to search out out!
Matthew Holt is the founder & writer of THCB. He’s simply left Blue Defend for Cigna. We suspect Cigna isn’t too completely satisfied about that.