In health care, mistakes happen, coding is complex, regulations are dense, and documentation systems vary, but when insurers use these technicalities to reverse payment long after care is rendered, it feels less like compliance and more like punishment.

My case wasn't fraud, it wasn't malpractice, it wasn't over billing. Instead, it was a missing ICD-10 diagnosis code on claim forms for care that were otherwise complete and medically necessary

I have been a contracted provider with a particular California health plan since around 1990, delivering care to their members for decades without issue. For years I've provided obstetrical services including prenatal visits, deliveries, and postpartum care – and was reimbursed accordingly.

But starting in 2023, everything changed.

First, my claims were processed and paid as usual, but only then to be notified months, or even years later, that I had to repay all the money back! The reason? A single ICD diagnostic code had been omitted from the original claim form. That’s right. One missing ICD-10 code. Not incorrect care, not lack of documentation – just one missing ICD-10 code was enough for them to demand full repayment for multiple patients for more than two years of service.

But why? We submitted the claim forms like we had done for years. Well, on page 52 of the manual of this health plan, there is a statement which states that there is a requirement that all claims for obstetrical services must include the gestational age, using the appropriate ICD-10 (Z3A) diagnostic code. Yes, this requirement was buried on page 52 of the manual. It was included in an appendix of the manual. To my knowledge, we never received any direct communication or alert regarding this. There were no emails. No bulletins. No notifications. Just a quiet line in a dense administrative document that most clinicians never see, let alone review line by line.

Moreover, the claims that we submitted were all paid without any comment. If even a single claim had been denied up front due to the missing gestational age diagnosis code, we would have immediately identified the issue and corrected it moving forward. A simple denial or a notice would have prevented the problem entirely. But they didn't. Instead, they continued to process and pay multiple claims over an extended period — without warning — only to come back months later and demand repayment for all of them. So, in other words, I, as a busy physician, was responsible for reading 52 pages of a manual from the health plan. However, the health plan themselves, apparently were not. They paid me for more than two years, ignoring page 52 of their own manual.

We appealed every single claim, submitting a corrected claim with the appeal. Some appeals were approved without explanation. Others were denied outright, even when the circumstances were identical. A few were simply ignored with no formal response or resolution. There was no clear standard. No transparency and no reliable way to predict the outcome. It felt arbitrary, like decisions were being made behind the curtain leaving us with few resources and mounting frustration. So, we did what any reasonable health care professional would do. We tried calling. But unfortunately, we were placed on hold for extended periods. When and if someone finally answered, we were sometimes told to call a different department. Other times, we left voicemails that went unanswered.

We reached out to the California Medical Association and to their credit, they did their best to advocate on our behalf. They appealed to the Department of Managed Care on behalf of multiple physicians. I wrote a letter to the president of the health plan asking for an executive review. Someone for the executive office contacted me and stated that their review concluded that the “physicians are responsible for abiding on what’s listed on page 52 of the manual.” They told me to follow the appeals process. When I told them that I had already appealed multiple claims without success, they just apologized without offering me any solution.

Still, after months, I still owe this health plan a considerable amount of money as they have not responded favorably to all of our appeals.

Any reasonable person can see this for what it is. It is abusive behavior cloaked in policy. We have spent countless hours trying to untangle this mess. Time that could have been spent caring for patients, teaching medical students or frankly, simply resting and spending time with my family.

And all of this, over care that was provided in good faith, documented appropriately and delivered with compassion. What's even more striking, is that to my knowledge, no other insurance carrier has done this. Just one. They have chosen to take back payments for legitimate care over a single missing diagnostic code.

It’s demoralizing to know that doing the right thing isn't enough to protect you from financial punishment. The system doesn't need to be perfect, but it needs to be fair. If we want to retain committed physicians, especially in high demand specialties like ob/gyn, we need to stop treating them like adversaries in an endless billing war.

We're not looking for handouts. We are looking for justice in a system that honors the care we give, instead of weaponizing hidden regulations against us.

Illustration by Jennifer Bogartz