By MATTHEW HOLT
More tales of the woes of dealing with health insurance. I live in Marin County, California and one of the things that comes with that is a diagnosis of ADHD for my children. (OK, I have made that joke before but it is true!). My kids now visit a psychiatrist for more sophisticated med management than they receive at their pediatrician. We were (until recently) on a Blue Shield HMO via the Covered California exchange.
While I was at the doctor’s office, I talked to the staff. They told me I owed a $50 copay. I didn’t pay them (yet) and I went online and saw the claim
The reasonable, informed consumer might think that I owed nothing. The clue being that
“Patient Responsibility” was $0.
But if you click the “See More” in the top right it shows you this
You probably still think that I owe $0. But if you add the numbers on the right you might notice they don’t total $0.
Just to make sure I go to the benefits section of the website. When I click on “Mental Health & Substance Use Disorder”, the top section is “Behavioral Health Treatment”. There’s a choice of “in home” or “In office”. This particular session was by telehealth but as I assume that is in office and I have also had some in office visits that looked the same, so I picked that. And there is a $0 copay.
So now the reasonable consumer sees a Patient Responsibility that’s $0 and a $0 copay
But I am not reasonable. So I click through to the EOB and see that there is a difference between what is allowed and what Blue Shield paid.
On the EOB it shows a $0 patient responsibility but a $50 co-pay/co-insurance charge. Which makes the $635 Blue Shield paid total the $685 they have (very badly) negotiated with UCSF. And yes they also let you see the PDF of the original EOB
This is the Schrodinger’s EOB because I owe $0 and $50 at the same time.
At this stage I call Blue Shield. No, they do not have a chatbot or a human chat function. It’s phone or nothing. Yes, it’s nearly June 2026.
After talking to their voice recognition system which still can’t recognize my birthdate or much else about me I eventually hit 0 enough times to get through to their barely audible customer service rep in the Philippines. There are multiple echoes and we can’t hear each other. The rep calls me back. It still is echoing horribly. Eventually she gives up and decides I need to speak to mental health customer service as this is a behavioral health claim. Even though it’s an office visit that looks like any other claim to me.
She puts me through. The voice recognition system answers again. Of course I had to tell it all my information again. It still can’t understand me and I hit 0 a few more times. Eventually I get an American-based rep working in the mental health claims team. None of the information I told the voice system transferred to the rep – even the bits I thought it did understand!
The rep told me that I owed $50.
So why was it showing me that I had $0 patient responsibility? Because in their mind/system I had already paid the $50 at the time of service, therefore it wasn’t my responsibility to pay it as I already had paid it. Even though I hadn’t! (BTW it was a telehealth visit with no way to pay but whatever).
But I did owe the $50 co-pay
So next I pointed out that the benefits on the website said there was a $0 co-pay. A-ha!
In fact if you read down in the fine print it says this
The rep told me that the $0 co-pay was for office based “treatment”. Had I scrolled down further I would have found the outpatient visit category. That does have a $50 co-pay. So I scroll down and she is correct.
But what distinguishes office based treatment from an office visit? Where is that in the fine print? In fact the fine print for both “treatment” and “outpatient” are exactly the same and never mentions what the difference is.
I asked the rep. Treatment, she told me, is specifically treatment for pervasive developmental disorder or autism. “Outpatient office visit” includes a whole range of diagnosis and in office treatments that she read off to me. I suspect that means that CPT code 90792, which is the one billed on the EOB, triggers “outpatient office visit” not “treatment”. Even though part of this session clearly is treatment!
CPT Code 90792 is used by psychiatrists, psychiatric nurse practitioners, and other medical professionals to bill for a Psychiatric Diagnostic Evaluation with Medical Services. It includes a comprehensive diagnostic assessment, medical history, mental status exam, and potentially medical decision-making for medication management
I suspect that the “treatment” category in the Blue Shield’s benefits list with the $0 co-pay is for CPT CPT codes (97151–97158) which are primarily used for Applied Behavior Analysis for behavior therapy for children with autism.
But who knows? They don’t tell you. They make it almost impossible to find out. And the EOB’s that Blue Shield issue have such shoddy UX it’s unlikely anyone understands what they should be paying.
It’s 2026 and while we have AI coming through the wazoo in our real lives, this major health plan just doesn’t seem to care about its customer’s experience.
And of course who but me would bother going through all this crap to find out!
Matthew Holt is the founder & publisher of THCB. He’s just left Blue Shield for Cigna. We suspect Cigna isn’t too happy about that.
