Matthew Holt
More stories about health insurance issues. I live in Marin County, California and one of the things that comes with that is my kids’ ADHD diagnosis. (Yes, I’ve made that joke before, but it’s true!) Our children now see a psychiatrist for more sophisticated medical care than they receive from their pediatrician. We (until recently) had a Blue Shield HMO through the Covered California exchange.
While I was in the doctor’s office, I spoke with the staff. They told me I would have to pay a $50 copay. I haven’t paid the bill (yet) and I went online to check the bill.
A rational, informed consumer might think I don’t owe anything. That’s the clue
“Patient responsibility” was $0.
But when I click ‘More’ in the top right, I see this:
You probably still think I owe $0. However, if you add up the numbers on the right, you will see that the total is not $0.
This is to ensure that you have navigated to the benefits section of the website. If you click on “Mental Health and Substance Use Disorders,” the top section is “Behavioral Health Treatment.” You can choose “At home” or “At the office.” This particular session was by telehealth, but I assumed it would be in the office and an office visit seemed the same, so I chose that. And the copay is $0.
Now the rational consumer sees $0 patient liability and $0 copayments.
But I am not rational. So I clicked on the EOB and saw that there was a difference between what was allowed and what Blue Shield paid.
The EOB shows $0 patient responsibility but $50 copay/co-insurance cost. So the $635 paid by Blue Shield is the $685 it negotiated (very badly) with UCSF. And yes, it is. You can also view a PDF of the original EOB.
This is Schrödinger’s EOB because I owe $0 and $50 at the same time.
At this stage we call it Blue Shield. No, there are no chatbots or human chat features. It doesn’t matter if it’s a phone call or anything. Yes, it’s almost June 2026.
After talking to a voice recognition system that still couldn’t recognize my date of birth or much else about me, I eventually zeroed in enough times to be connected to a barely audible customer service representative in the Philippines. There are multiple echoes and they cannot hear each other. The representative called me again. It still resonates horribly. Eventually she gave up and decided that since this was a behavioral health claim, she should contact mental health customer service. Even though it was an office visit that seemed like any other argument to me.
She connected me. The voice recognition system responds again. Of course I had to repeat all my information. It still didn’t get me and I hit zero a few more times. I ended up getting a US based representative who worked on the mental health claims team. None of the information I spoke into the voice system was relayed to the representative. Even the parts I thought I understood!
The representative said I owed $50.
So why did you show me that I have absolutely no patient responsibility? Because I was in their mind/system. already paid So since I paid $50 for the service, it wasn’t my responsibility to pay. Although I didn’t! (By the way, it was a telehealth visit with no way to pay for it, but whatever).
But I had to pay a $50 copay.
So next I pointed out that the benefits on the website said there was a $0 copay. aha!
In fact, if you read the small print, it says this.
The representative said the $0 copay was for office-based “treatment.” If you had scrolled further down, you would have found the Outpatient Visits category. There is a $50 copayment. So I scrolled down and she was right.
But what is the difference between clinic-based treatment and office visits? Where is that in small print? In fact, the fine print for “treatment” and “outpatient” is exactly the same and doesn’t mention what the difference is.
I asked the person in charge. She said the treatment is specifically for pervasive developmental disorders or autism. An “outpatient office visit” includes a variety of diagnoses and office treatments that she reads to me. I suspect this means that the CPT code 90792 billed to the EOB results in an “outpatient clinic visit” and not a “treatment.” Part of this session is definitely therapeutic!
CPT code 90792 is used by psychiatrists, psychiatric nurse practitioners, and other health care professionals to bill for psychiatric diagnostic evaluations through health care services. This includes a comprehensive diagnostic evaluation, medical history, mental status examination, and potential medical decisions for medication management.
The “therapy” category in the Blue Shield benefit list, which has $0 copayments, appears to be primarily for CPT CPT codes (97151-97158) used in applied behavior analysis for behavioral treatment of children with autism.
But who knows? They don’t tell you. They make it almost impossible to find out. And the EOB in question with Blue Shield has a UX so sloppy that no one will understand what they’re paying for.
It’s 2026 and while AI is happening in real life, this major health insurance doesn’t seem to care about their customers’ experience.
And of course, who else but me would go through all of this and try to figure it out!
Matthew Holt is the founder and publisher of THCB. He just left Blue Shield for Cigna. We suspect Cigna isn’t too happy about that.
