One of the funniest claims incidents I ever worked on, back when I was in direct customer service, involved a denial for a week-old baby’s first well baby check. The carrier’s denial code indicated that the service was not medically necessary.
His mother, of course, was understandably irate by the time she got my name and number. “How could they say a well-baby check on a week-old baby isn’t medically necessary?”
I wanted to know the same thing, so I asked her to send her Explanation of Benefits (EOB). She did so and the minute I looked at it, I burst out laughing. Fortunately I wasn’t on the phone with her at the time, so I was able to take a second and compose myself before calling her back.
“Ma’am,” I explained. “This EOB says you were the patient. Not your child. They denied it because adults really don’t need well-baby checks.”
She was dumbfounded. “They — what?” And a moment later, she was laughing too.
I went on to tell her that she just needed to have the doctor’s office correct the patient information and resubmit the claim. She did so, the practice resubmitted the claim, and everything went through without a hitch.
The error had been compounded by the fact that the provider in question was a family medicine practitioner and really did have adult patients. Thus, the computerized automatic-adjudication system had not had any indicators to warn of a mismatch. Instead, it simply denied the claim. Once we unwound the problem, that claim was moved from being listed as “denied” to being listed as “appealed, overturned, and paid.”
In other words: a minor — and understandable — administrative error that had been corrected with about thirty seconds’ work was added to that year’s statistics about the carrier’s overturned denials.
Just one of those things, right? Maybe. But maybe not.
According to the CDC, the United States had about 3.6 million births in 2025. The recommended well-child schedule includes checks when a baby is a few days old, and then again at 1, 2, 4, 6, and 9 months. That’s a total of six checks per child during the first nine months of life. With roughly 3.6 million babies being born each year, that suggests something on the order of 21.6 million well-baby checks recommended every year.
Even at an administrative error rate of 0.01% — one in ten thousand — that could potentially mean over two thousand of those claims were ultimately listed as “denied, appealed, overturned, and paid.” In one year! For a simple administrative error! On well-baby checks alone!
How many other medical services are performed every day in this country, generating claims 365 days a year? The numbers become mind-boggling extremely quickly, even if, as we do above, we assume an administrative error rate that’s nearly thirty times lower than one published estimate for an ordinary human task.
And that’s the problem with looking at claims denials as nothing more than numbers.
A denied claim tells us that a claim was denied. An overturned claim tells us that the original denial was later reversed. Neither statistic, by itself, tells us why.
Sometimes the answer really is that the carrier got it wrong. Sometimes additional medical records or other information changed the outcome. Sometimes the provider corrected a coding or billing problem. Sometimes someone simply typed the wrong information into the wrong field. And sometimes, apparently, a slip-up lists an adult parent as the patient during a child’s well-baby check.
None of that means denial statistics aren’t important. They are. But if we’re going to use those statistics to understand how well — or how poorly — our health coverage system is working, we need to understand what the numbers actually represent.
And to do that, we need to start considerably earlier in the process.
What actually happens when your doctor “sends a claim to the insurance carrier”? What information is on that claim? Where does it come from? How is it used and when?
In the next post in this series, we’ll take a claim submission apart piece by piece and look at the problems that can develop before it even gets transmitted to your health carrier. Because before we can understand why claims go wrong, we need to understand how much has to go right.