Health Insurance Claim Denials: Fighting Back

Patients need to become their own advocates against hidden health costs.


Then, if a patient is surprised to discover that a claim is later denied, Morphew recommends calling the insurer to check on the reason. The doctor could have submitted the wrong information or made a coding error, for example. If that doesn't resolve the problem, then she suggests following up with the doctor and possibly filing an appeal with the insurer with any relevant information from the doctor's office, including the reasoning for why the procedure was done. "If you think it's something that should be covered, you need to call, and not take 'No' for an answer, and keep going until you find out what the answer is," Morphew adds.

In the end, it seems to me that both Aetna and my doctor's office could have handled the situation better. When Aetna receives a claim for the more complex ultrasound, it could pay for it up to the amount of the routine ultrasound that it would have paid for in full. Otherwise, patients in my situation get no coverage, despite paying for it all these years. As for the doctor, she could have presented me with a choice between receiving the standard and the more complex ultrasound, so that I could decide for myself, instead of just billing me for the more expensive one.

Ultimately, I received a minor victory: After I asked my doctor's billing office for the discount that it normally provides to insurers, my bill went from $612 to $332—a savings of $280. On Morphew's recommendation, I filed an appeal with Aetna, but it was denied. Aetna's response said that after reviewing my medical records, it found that I received only a standard ultrasound and my doctor used the wrong code. (My doctor vigorously denies this and says that the more complex ultrasound was performed.) The next option is for me to initiate an external review of the situation through the state appeal office. According to America's Health Insurance Plans, which represents insurers, about 60 percent of appeals filed through states are upheld—in other words, the reviewers agree with the insurer. In 37 percent of the cases, they agree with the consumer.

Meanwhile, as my baby's due date approaches, I wonder what other hidden costs await us.