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Price Transparency Data Reveals the Real Story Behind Capital Women’s Care vs UnitedHealthcare Contract Battle (Part 1)

By JASON HINES

On August 1, 2025, Capital Women’s Care (CWC), one of the largest OB/GYN practices in the Mid-Atlantic region went out-of-network with UnitedHealthcare, affecting tens of thousands of women across Maryland, Virginia, Pennsylvania, and Washington D.C. The contract dispute between Capital Women’s Care (CWC) and UnitedHealthcare offers a fascinating case study in how price transparency data can illuminate the real dynamics behind these high-stakes negotiations.

The Public Battle

Capital Women’s Care, with more than 250 physicians and healthcare professionals, confirmed that its agreement with UnitedHealthcare would lapse despite ongoing negotiations. The practice urged patients to contact UHC to voice their concerns about losing access to their providers.

UnitedHealthcare fired back with detailed public claims on their website, alleging that CWC “refused to move off its demands for double-digit price hikes” and is “significantly higher cost today compared to peer providers throughout Maryland and Virginia”. UHC provided specific examples, claiming that a vaginal delivery from CWC would cost “more than 120% higher – or over $2,600 more – than the average cost of other OB/GYN providers”.

But what does the actual price transparency data reveal about these competing claims?

What the Transparency Data Shows

Using Capital Women’s Care’s negotiated rates from UnitedHealthcare’s own machine-readable files, we analyzed a sample of common OB/GYN procedures from Maryland rate data. While this represents only a subset of all procedures and focuses specifically on Maryland rates, it provides valuable insights into the real payment dynamics between these organizations. The data paints a more nuanced picture than either party’s public statements suggest.

Data Methodology Note: Our analysis examined negotiated rates for Capital Women’s Care from publicly available machine-readable files, focusing on Maryland providers and filtering out statistical outliers (rates below 50% or above 500% of Medicare). We analyzed rates for both UnitedHealthcare and CareFirst across three common OB/GYN procedures where both payers had sufficient data.

CWC’s Rate Position vs Other Payers

Our analysis of three common OB/GYN procedures in Maryland reveals that CWC’s rates with UnitedHealthcare were actually quite competitive compared to other major payers:

Negotiated rates for three common OB/GYN procedures show UHC was paying competitive rates compared to CareFirst

For the three procedures where both UHC and CareFirst have negotiated rates with CWC:

  • CPT 56515 (Vulvar Lesion Destruction): UHC paid $401 vs CareFirst’s $617 (53.9% difference)
  • CPT 57288 (Sling Operation): UHC paid $1,163 vs CareFirst’s $1,254 (7.8% difference)
  • CPT 58558 (Hysteroscopy): UHC paid $2,294 vs CareFirst’s $2,318 (1.0% difference)

This sample data suggests UnitedHealthcare was already getting favorable rates from CWC compared to other major payers, calling into question UHC’s claims about CWC being “significantly higher cost.”

The Medicare Benchmark Reality

Both UHC and CareFirst were paying CWC rates well above Medicare in our sample:

  • UnitedHealthcare: 143-175% of Medicare rates
  • CareFirst: 166-220% of Medicare rates

While CareFirst paid higher rates, UnitedHealthcare’s rates were still substantial premiums over government reimbursement, suggesting the “double-digit increases” CWC requested may have been attempts to align with market rates other payers were willing to pay.

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Why U.S. Healthcare Pricing Transparency Laws Will Fail Without Real Penalties

By CHINELO GRACE CHIGOZIE

The U.S. has a healthcare cost problem that everyone knows about but no one talks about openly. For decades, the same medical treatment has cost very different amounts. Hospitals down the street from each other might charge five times more or less for the exact same thing. Patients couldn’t find out the real costs ahead of time. Even many insurance companies didn’t know the actual rates. Two recent laws tried to fix this problem. The Hospital Price Transparency Rule came into effect in 2021. The No Surprises Act came into effect in 2022. These laws have two main goals. First, they need healthcare providers to share their real prices. Second, they aim to stop some unfair billing practices.

On paper, these measures should have transformed the market. Patients would “shop” for cheaper care. Providers would compete, driving down prices. Insurers would negotiate with real market benchmarks. But three years in, the impact is scattered and superficial. Compliance is inconsistent. Prices remain incomprehensible to ordinary consumers. In some markets, transparency has even led to higher prices. The main problem is that the laws don’t have strong enough punishments.

The Transparency Mirage

CMS is a government agency. It checks if hospitals follow the Hospital Price Transparency Rule. Hospitals can be fined $300 to $5,500 each day if they break the rules. The fine depends on the hospital’s size. That sounds serious until you consider scale: the average fine in 2022 was about 0.49% of a hospital’s revenue. For large systems with multi-billion-dollar budgets, it’s a rounding error. Many hospitals can easily afford the small fine and keep breaking the law. And many do. A CMS report from April 2023 showed that 70% of 600 hospitals followed the rules. But independent audits show a different picture. A July 2025 review of 2,000 hospitals found only 36% fully compliant, up from 24.5% five months earlier.

A November 2024 study found that 46% of hospitals did not follow all the rules. The patterns are the same everywhere. Hospitals share incomplete data. They create machine-readable files that are hard to use. They hide “shoppable service” lists in website folders. Search engines cannot find these folders. The No Surprises Act was meant to stop surprise bills for some out-of-network care. But it hasn’t worked much better. The law has stopped millions of surprise bills. But the dispute process (the IDR) has more cases than it can manage.

From early 2023 to mid-2024, people filed 1.24 million disputes. Forty-one percent of these cases are still waiting for a decision. Providers win most emergency disputes – about 85% of them. They often get paid more than what insurers first offered. This makes healthcare costs go up for everyone. The system needs tough penalties for insurance companies that are slow to pay or refuse to pay. Without these penalties, the system will stay clogged up forever.

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Ingrid Lindberg, Sobrynth

Ingrid is one of the OGs of customer service in health plans, PBMs and as she insists startups. She and her co-founder Marin Nelson have built Sobrynth–a company that is taking a whole new approach to helping with (primarily) alcohol addiction in the workplace. Despite the rise of mental health solutions, EAP, the focus on substance abuse and a lot of DTC plays in alcohol use disorder (starting with AA and going on from there), there’s not much specifically for employers. Ingrid showed me the app, the process and we had a great chat about the problem and how Sobrynth can help–Matthew Holt

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

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

Which Platform of Platforms (UDHP) is Right for your Health System? A Market Analysis

Neil Jennings
Vince Kuraitis

By NEIL JENNINGS & VINCE KURAITIS

This entry is part 5 of 5 in the series Platforming Healthcare — The Long View

In previous posts in this series, we have covered the definitions of Unified Digital Health platforms and whether “EHRs can become UDHPs.” In this follow-on post, we’ll talk through the requirements for success for a UDHP and which types of healthcare organizations are best suited for which types of UDHPs. This post will build on findings from the previous posts.

The Market Needs UDHPs: Key Takeaways from Previous Posts

UDHP Framework

Key Takeaway 1: The healthcare industry needs UDHPs to create a centralized, common architecture for healthcare organizations

Key Takeaway 2: The healthcare organizations leveraging UDHPs will achieve a myriad of benefits, from competitive advantages to clinical, financial, and operational gains

Key Takeaway 3: UDHPs are not all-or-nothing or mutually exclusive from EHRs. As we explored in our last post, EHRs could expand into UDHPs. These EHRs as UDHPs (or the relative platform of platforms) may be the optimal choice for some market segments. EHRs may also be accommodated into cloud-first UHDPs.

Key Takeaway 4 / Guiding Criterion: This post will focus on US regional and local health systems and outpatient groups of all sizes.

The Approach: Market -> Segments -> Options -> Fit

  • For this post, we will start from the top-down market perspective, analyzing the overall market landscape.
  • Once we have described the landscape, we will call out the key segments (organization types, sizes, and profiles) that we will be evaluating.
  • At this point, we will approximate IT budgets and IT team sizes by organization type to determine capabilities of building as opposed to depending on partners and vendors.
  • Then, we’ll review the constraints for implementation and ownership, outlining the drivers of UDHP fit.
  • Next, we’ll break down the different ways UDHPs can be developed and maintained.
    • Leveraging an EHR as UDHP
    • License from UDHP vendor
    • “Home grown” cloud-first solution
  • Finally, we’ll crosswalk the segments and the optimal option for each segment, based on their specific needs and estimated IT and budgetary resources.

The Healthcare Market & Major Health System Segments

Starting with a compelling graphic from the Kaiser Family Foundation, we see a 2023 breakdown of the total US healthcare medical expenditure, totaling ~$4.9 trillion.

While the total healthcare spend that occurred in hospitals is an astounding ~$ 1.5 trillion, accounting for 31% of total healthcare spend, this leaves much of care outside the four walls of hospitals. This amount of care occurring outside of hospitals aligns with efforts to push patients into less acute care settings, emphasizing preventative, proactive medicine instead of acute, reactive medicine. As the need for UDHPs applies to more than inpatient hospitals, we will also review the other segments highlighted in the pie chart, including: outpatient clinics and practice groups, and “other health” containing services delivered at other contexts like PACs and SNFs, and Ambulatory surgical centers.

Continue reading…

When is Preventative Care not Preventative? Let’s get Labcorp to join in! (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

Matthew Holt is the founder and publisher of THCB

Après AI, le Déluge

By KIM BELLARD

I have to admit, I’ve steered away from writing about AI lately. There’s just so much going on, so fast, that I can’t keep up. Don’t ask me how GPT-5 differs from GPT-4, or what Gemini does versus Genie 3. I know Microsoft really, really wants me to use Copilot, but so far I’m not biting. DeepMind versus DeepSeek?  Is Anthropic the French AI, or is that Mistral?  I’m just glad there are younger, smarter people paying closer attention to all this.

Still, I’m very much concerned about where the AI revolution is taking us, and whether we’re driving it or just along for the ride. In Fast Company, Sebastion Buck, co-founder of the “future design company” Enso, posits a great attitude about the AI revolution:

The scary news is: We have to redesign everything.

The exciting news is: We get to redesign everything.

He goes on to explain:

Technical revolutions create windows of time when new social norms are created, and where institutions and infrastructure is rethought. This window of time will influence daily life in myriad ways, from how people find dates, to whether kids write essays, to which jobs require applications, to how people move through cities and get health diagnoses.

Each of these are design decisions, not natural outcomes. Who gets to make these decisions? Every company, organization, and community that is considering if—and how—to adopt AI. Which almost certainly includes you. Congratulations, you’re now part of designing a revolution.

I want to pick out one area in particular where I hope we redesign everything intentionally, rather than in our normal short-sighted, laissez-faire manner: jobs and wealth.

It has become widely accepted that offshoring led to the demise of U.S. manufacturing and its solidly middle class blue collar jobs over the last 30 years. There’s some truth to that, but automation was arguably more of a factor – and that was before AI and today’s more versatile robots. More to the point, today’s AI and robots aren’t coming just to manufacturing but pretty much to every sector.

Former Transportation Secretary Pete Buttigieg warned:

The economic implications are the ones that I think could be the most disruptive, the most quickly. We’re talking about whole categories of jobs, where — not in 30 or 40 years, but in three or four — half of the entry-level jobs might not be there. It will be a bit like what I lived through as a kid in the industrial Midwest when trade in automation sucked away a lot of the auto jobs in the nineties — but ten times, maybe a hundred times more disruptive.

Mr. Buttigieg is no AI expert, but Erik Brynjolfsson, senior fellow at Stanford’s Institute for Human-Centered Artificial Intelligence and director of the Stanford Digital Economy Lab, is. When asked about those comments, he told Morning Edition: “Yeah, he’s spot on. We are seeing enormous advances in core technology and very little attention is being paid to how we can adapt our economy and be ready for those changes.”

You could look, for example, at the big layoffs in the tech sector lately. Natasha Singer, writing in The New York Times, reports on how computer science graduates have gone from expecting mid-six figure starting salaries to working at Chipotle (and wait till Chipotle automates all those jobs). The Federal Reserve Bank of New York says unemployment for computer science & computer engineering majors is better than anthropology majors, but, astonishingly, worse than pretty much all other majors.

And don’t just feel sorry for tech workers. Neil Irwin of Axios warns: “In the next job market downturn — whether it’s already starting or years away — there just might be a bloodbath for millions of workers whose jobs can be supplanted by artificial intelligence.” He quotes Federal Reserve governor Lisa Cook: “AI is poised to reshape our labor market, which in turn could affect our notion of maximum employment or our estimate of the natural rate of unemployment.”

In other words, you ain’t seen nothing yet.

While manufacturing was taking a beating in the U.S. over the last thirty years, tech boomed. Most of the world’s largest and most profitable companies are tech companies, and most of the world’s richest people got their wealth from tech. Those are, by and large, the ones investing most heavily in AI — most likely to benefit from it.

Professor Brynjolfsson worries about how we’ll handle the transition to an AI economy:

The ideal thing is that you find ways of compensating people and managing a transition. Sad to say, with trade, we didn’t do a very good job of that. A lot of people got left behind. It would be a catastrophe if we made the similar mistake with technology, [which] that also is going to create enormous amounts of wealth, but it’s not going to affect everyone evenly. And we have to make sure that people manage that transition. 

“Catastrophe” indeed. And I fear it is coming.

Continue reading…

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!

Matthew Holt is the founder, author and publisher of THCB

Where “Little Flowers” Bloom – Two by Two

By MIKE MAGEE

What are the chances that citizens of New York, the largest city in the nation, would vote in a majority to oppose a formerly corrupt politician with a party machine behind him, and instead favor a little known candidate – the son of immigrant parents with “swarthy skin and belligerent independence,” from a suspect minority and religious heritage, who actively mixed music and politics, who seemed to come out of nowhere but be everywhere at once, and was ultra focused on “efficiency and honesty in municipal government?”

And what if that had occurred not once, but twice in the last century?

Certainly by now, the name Zohran Mamdani is already ringing in your ears. More on him in a moment. But let’s first travel back a century to introduce another candidate for mayor whose life and career presaged the modern day version.

His name was Fiorello La Guardia, and his remains were laid to rest on September 21, 1947 in Woodland Cemetery, a short distance from his home at 5020 Woodbridge Avenue in the Riverdale section of the Bronx. He died at age 64 from pancreatic cancer.

“The Little Flower” (a nickname that derived from his first name Fiore – Italian for flower) described his stature (5 foot 2 inches) but not necessarily his personality. The New York Times obituary described him “as much a part (of New York) as any of its public buildings” and “a little firebrand.”

By any measure, he was one of New York’s own, earning the morning of his death in 1947 the Fire Department’s 5-5-5-5 signal, a traditional bell code used to honor firefighters who have died in the line of duty.

An Italian immigrant, his father was raised a Catholic in Foggia, Italy, and his mother (from Trieste on the Italian/Croatian border) was Jewish.  Fiorello was born on the East Side of Manhattan on December 11, 1882, two years after his parents’ marriage in Italy. His father was a skilled musician and became the bandmaster for the U.S. Army. As a result, Fiorello was raised on multiple Army bases, and graduated from high school in Prescott, Arizona, a stone’s throw from Fort Whipple. Along the way, the father taught the son to play the banjo, cornet, and trumpet, and taught his sister, Gemma, to play violin, mandolin, and piano.

Skilled in languages (Yiddish, German, French, Italian), by the age of 20 Fiorello was employed by the US Consulate in Europe, and on return to the U.S. served as an interpreter on Ellis Island. Within a few years, he managed a Law Degree from NYU in 1910, and in 1914, at age 32 ran for U.S. Congress as a Republican, losing to the Tammany Hall’s Democratic candidate. Two years later, he won the seat even though Republicans initially supported another candidate. By 2018, he was re-elected but this time with Democratic support and declaring himself a “socialist.”

By 1933, Tammany Hall and its leader, NYC Mayor Jimmy Walker, were out, clearing the way for Fiorello. He ran with the support of a complex coalition of German American Republicans, Democratic reformers, Socialists, middle-class Jews, and Italians who in the past had aligned with Tammany Hall.

He came into the Mayor’s office in 1934 good to go. He had promised work relief for the unemployed, merit-based civil service, efficiency over corruption, and a focus on infrastructure including expanded housing, transportation and parks. Robert Moses was the head of his Parks department, a post he held until 1960. His vocal support during the election for FDR paid off handsomely. Fully 20% of the entire national Civil Works Administration (CPA) budget was allocated by FDR to New York City. In return, he delivered his Labor Party’s (which he helped organize) support to FDR in his Presidential elections in 1936, 1940 and 1944.

One of his main achievements was the maintenance of the Office of Price Administration which placed limits on pricing of food, rents, and other necessities. By the time he stepped down on December 31, 1945, “Tammany Hall had been reduced to a shadow.”

Eight decades later, an independent minded, gifted politician, also occasionally self-defined a “socialist” bucked his own political establishment and soundly defeated the modern version of a Democratic Tammany candidate, Andrew Cuomo, surprising many, but not all political pundits. His name is Zohran Mamdani.

Continue reading…

Ami Parekh & Ankoor Shah, Included Health

Ami Parekh is the Chief Health Officer & Ankoor Shah, is VP, Clinical Excellence at Included Health. I had a long conversation with them about the philosophy of how we are doing population health and how we fix the system that we have today. I’m arguing for more primary care, but Ami restated it and says, you need somone you trust who is an expert who can help you make decisions. And this might not be a human! How do we change the system, and how does telehealth work now and how will it change? Defining health from the person perspective, not the way the health system wants to define it! Matthew Holt