What Does Medical Necessity Mean, and Why Should You Care

Video Transcript

Joyce Griggs: Hello everyone. I'm Joyce Griggs for United States of Healthcare. Welcome to our conversation with our insurance experts, Dr. Alan Feren and Jordan Shields. They're here today to talk to us about medical necessity, what it is and what it means, and why it's important that we understand it when it comes to our insurance, because this is what our insurer uses to determine what they will cover.

Dr. Feren has many, many years of experience, decades in fact, working on both sides of the stethoscope. As a patient, as a patient advocate, and also as a surgeon and a leading expert, in fact, a medical director and a large insurance provider. Jordan Shields, likewise, decades of experience working in the insurance industry as a consultant, author, and sought after speaker, as well as a broker helping individuals like you and me find insurance plans that are right for us and for our families.

Today, we unpack medical necessity and why we need to understand what that means.

Welcome everyone. We're so delighted to be here with you. Alan or Jordan, which one of you just want to kick it off and just tell us what we're going to talk about when we talk about medical necessity.

Alan Feren, M.D.: Well, I think the first thing is to define what is medical necessity, because there's a lot of confusion.

The problem really is when your doctor or healthcare professional has prescribed something for you and then you get a letter from the insurance company and it says, this has been denied because it's not medically necessary. How do you coordinate this? Because here you have a professional, licensed, probably boarded, who's prescribed something for you and can be a procedure, can be a drug, and that the insurance company is saying Uhuh, but it's not medically necessary. How do you reconcile those two issues?

So we're gonna talk a bit about that. What's the definition? And then we're gonna talk about the different components because there's, there's a lot of things that kind of go into this witches brew of medical necessity.

Things like, who determines what is medically necessary? How is that done? Are there committees? Are there people? What is peer review? Peer reviewed articles, how does that go into play? Jordan, do you wanna chime in?

Jordan Shields: The biggest problem you have is that you've got an insurance company that can't wait to crank out 150 or a 200 page contract, tell you everything you don't wanna know about the insurance, but then when you get the benefit statement back from the company says "not medically necessary," three words. And. Are you gonna have a footnote with that? You wanna elaborate on that a little bit? No, it's just not medically necessary. So now you have to go to the trouble of unpacking what that's supposed to mean and say, okay, where do I go?

And so what we're gonna be discussing today is: where do you go? How do you get there? What do you do? When do you get there? What do you need to have so that you can push back at the company and say, what do you mean it's not medically necessary? Let me tell you something. So we want to be able to give you the tools to have a, a dialogue if such a thing is possible with a monolithic, bureaucratic insurance company and say, you're gonna have to explain that a little bit better. Here's what I know. So we're gonna be talking about that today.

Alan Feren, M.D.: I think a good place to start is Medicare's definition, which is very simple. It's services and supplies necessary to diagnose and treat a medical condition. From there, there's this outflow of, well, okay, what does that really mean?

And what that means is that there are tried and true procedures, drugs, services that are embedded in every health plan's medical policy determination. And there are committees that are staffed by professionals in insurance companies, medical people like myself and other experts that determine medical policy.

And it's, it's a moving target and it changes annually.

Jordan Shields: Or daily. Weekly, or whatever. Yeah.

Alan Feren, M.D.: Yeah. Cuz we do know that medical technology is advanced on a regular basis.

Joyce Griggs: Right.

Alan Feren, M.D.: And that's particularly true with new drugs. I mean, if you sit and watch TV for any period of time, there are, you know, 15 different unpronounceable, undistinguishable drugs that have more problems and complications than the therapeutic equivalent is found on the drug itself.

Jordan Shields: Well, the good news is they all treat erectile dysfunction. And one of the things Alan alluded to a second ago, he says, you know, it changes annually. The big problem is that medical technology and advances does not change annually, but by the time the carrier or their committees get through reviewing the current literature, that is annually.

So they review it in December. You've been told you need something in February, you have to wait 11 months for them to get around to saying, oh yeah, you're right.

Joyce Griggs: Let me just unpack a couple of things with you because medical necessity means something different to every different health plan, right?

So it's not like there's a thing called medical necessity. And what's considered medically necessary by one plan may not be. Considered medically necessary by another. Is that true?

Jordan Shields: Well, yeah, but what Alan referred to the Medicare definition, that's a pretty good standard, common sense approach that the carriers are basically looking at.

I mean, what is required to treat, mitigate, whatever situation. Where it differs by carrier is what their committees have to say. You've got a new procedure, a new drug, a new something, and you have this committee that's reviewing that to say, are we considering this medically necessary? Will we cover it once it's been FDA approved and so on?

And that can vary, but I will tell you in my experience, the variance is not large.

Joyce Griggs: Okay.

Jordan Shields: It really just comes down to, do you need this? Do we believe you need this? Who's gonna prove you need this? And is it actually going to improve your situation? One of the unknown things or one of the unspoken things about medical necessity is that what you're getting done may be appropriate treatment in general, but it may not actually improve your situation. And the doctor who's eager to make you happy and make you better is also playing to your desire to give me something, tell me something, anything will do. And when they tell them that and the insurance company goes, hold on a second, you know, what are, what are we accomplishing here?

So I don't take the side of the insurance company, but because I've been working with carriers for 45 years, I get where they're coming from and it's conservative. It's, we don't wanna pay this if we don't have to, but sometimes they have a point. And I've, I've spoken to patients who said, well, the doctor said so and so, and I'm listening to it going, I'm not buying it and I'm on your side. It's a fine line that, that they, and we walk, and part of our job when we deal with clients is to say, all right, let's pull back. Here's what's going on.

So the short answer to your question is there's not a great deal of variance, but the key differences come down to how the carrier's looking at it with their committee, and then they're gonna come to pretty similar conclusions.

Joyce Griggs: So, I get a denial, Alan. And it says it's deemed not medically necessary. What is the first thing that I do to understand what's happened to me.

Alan Feren, M.D.: Yeah, there's a booklet that is sent to everyone called the Evidence of Coverage or EOC. And in that it lists the various things that your health plan will not cover. So it's a good time to investigate because the last thing you wanna do is go down this road of denial. And in fact, it's because of something that's clearly stated in the health plan. Oftentimes some of these denials are just administrative errors. They, it could be the wrong person, you know, you have a family that's enrolled in a health plan and they have the wrong person. It can be a problem with the dates, it can be any of these minor type problems, and those are solved and resolved very easily. But if something that you've undertaken, had a procedure and you haven't followed the rules, like something as simple as prior authorization where it's the "mother may I" situation and you fail to do that, then it's gonna be denied. Or akin to that is second opinion. If procedures requires a second opinion, and you didn't get it, then it's gonna be outright denied. So it's important to really look at the language, look at what was, was denied, and understand it.

That's the absolute first step.

Joyce Griggs: Mm-hmm. And is there something that I can do before, so we're talking about this kind of retrospectively, one of us has gotten a denial letter. What can we do to avoid getting one of these denial letters? Is there anything that we can do?

Jordan Shields: Yeah, you could do everything that Alan just said and do it beforehand. I mean, assuming it's a non-urgent situation. If I'm going, like, I am going in for knee surgery in a couple of months, so I have plenty of time to figure out who, what, where, why, and what I need to do to make sure the claim is gonna go through, get the prior authorization, and so on. That happens most often. So what we tell clients when, especially when we're having a, a meeting with all the employees, they'll say, look, here's who I am. Here's what I do. Here's my card. Everything I say after this, you're not gonna remember. So remember, here's who I am, here's what I do, and here's my card. Call me when something comes up. So when you're told that you have cancer, you, you know, need this surgery, then call me and we'll walk you through it then. Or talk to your office manager, talk to your HR manager, whoever. I have a problem now. I haven't read it until now, which you shouldn't really. Now I need to read it. Before you get started. It's when you go down the road and we have to clean it up retrospectively, retroactively, then you can run into problems. Cuz now the money's spent, the dye is cast, and someone's coming looking for you.

Joyce Griggs: Yeah. Yeah.

Alan Feren, M.D.: I think it's also not unreasonable for procedure-based issues like the knee surgery to kind of touch bases with your doctor. Do you need a second opinion? Does this need to be prior authorized? Because doctors really know, people who are doing these types of procedures know exactly what needs to be done.

Jordan Shields: Specialists do, specialists do, Alan, and the general practitioner, family practitioner doesn't always know that as well, but the specialists definitely do. You're quite right. So the knee surgery, you know, you talk to the orthopedist, they're doing this 20 times a day talking to carriers and all that, you're quite right.

Joyce Griggs: So just to summarize, like what we're saying is if you have something that's not emergent and that you know, okay, get preparing for a surgery, look over your Evidence of Coverage, talk to somebody like one of you, if you have somebody like that in your, in your life or your HR manager or even your doctor, their staff, probably there's somebody in a specialist office in particular dedicated on staff who will go through all the steps to make sure that you get that. If it's a prior authorization or, or a second opinion, or whatever else you need so that you know that you're not gonna get a denial letter that this is not medically necessary according to the insurance company.

Jordan Shields: What's that old thing saying? Prevention's worth the pound of cure, this is prevention right here.

Joyce Griggs: Mm-hmm. Right, right. So important. Now, I know we talked about this a little bit, but I'm wondering if we can go back to it a little bit. So we have the Medicare definition of what is medically necessary, but health plans, like you mentioned before, they're not just making this up. I mean, it's based on evidence, right? In terms of what's deemed medically necessary? So they're using certain bodies of evidence from major organizations, is that right? To determine what's medically necessary. Can we feel good about what they've determined as medically necessary?

Alan Feren, M.D.: Yeah, I agree with that statement. Having sat on these medical policy committees, the Medicare really is almost the kind of the bellwether in their determinations. Sometimes they're behind the curve, but oftentimes health plans look to the Medicare medical policy guidelines for their guidance. The Blues have a medical policy group called the Medical Policy Committee On uh, Medicine and Technology. And you've got a lot of blues plans throughout the US. And so some of the other non-major health plans and other major health plans use those determinations. But there are state and federal guidelines that have to be adhered to as well. If you're a Medicare patient, you can go on medicare.gov and see what is considered to be medically necessary. You can put in your particular procedure.

Joyce Griggs: Right.

Jordan Shields: I should mention one thing related to the claim denial and what Alan's talking about with committees. Even though there may be medical policy guidelines set by the carriers, the Blues by the way is Blue Cross Blue Shield or it's Aetna or it's Medicare or whatever. When the claim comes across somebody's desk, they're not thinking in terms of the totality of all that has gone before them and all the committee has said and trying to figure out if they look at the paperwork, if they can uncover the nuances of your medical care. They, they don't have that kind of time, they don't have that kind of inclination. So they may just say, I don't get it, and then just say, claim denied.

Or they say, I know what the committee says. Yeah, based on what they're saying, I don't get it. So a lot of times you know, we don't see this as medically necessary is their way of saying, we don't understand it. We don't get it. You're gonna have to give us more information. But right now, based on what we are seeing or what we know, it doesn't appear to be medically necessary based on committee guidelines, based on internal administrative guidelines, based on common sense, or based on a lack of complete information, which is what we're alluding to in the overview.

Joyce Griggs: Mm-hmm. So if I'm maybe wanting to get something that might be deemed, I don't know, experimental or investigational treatment or procedure, would that be something that would automatically be determined as not medically necessary or what, what happens in those cases?

Alan Feren, M.D.: It's pretty much the reverse.

Joyce Griggs: Okay.

Alan Feren, M.D.: When there is something that's, that hasn't been shown in the literature to be equally effective and safe as an existing either drug or treatment, it will be deemed to be investigational or experimental. But, if there is solid literature that's peer reviewed, in other words, it's looked at by experts, the same experts in that particular field, and there are good studies, and the gold standard is what's called a random controlled study where you have a group of people who are not undergoing the same type of treatment either using a, a medication or a procedure. And then a group of people that are, and the outcome needs to be as good as or better than before it's deemed to be acceptable and approved.

So the bottom line really is your doctor needs to work with you if there is a determination that it's experimental or investigational. Find the literature that supports that and we'll get into that more, I think, when we talk about the appeal process, because that's a very central portion of the appeals.

Jordan Shields: Well, let's go back to the prevention thing. So sometimes, sometimes the carrier will say in the benefit statement, "experimental investigation." Not often, but sometimes, so that, that's helpful.

But the prevention thing, if you're talking to your doctor and your doctor says, well, we could try this. As soon as their eyes begin to go this way or that way, that's when you wanna say, well, when you say "we," who's gonna pay for it? It's always good to just ask them and I've been in this situation, just ask 'em the question. Well, doctor, is this the standard? Everybody does it. You do this 15 times a day type of thing? Or is this, let's give this a try because I heard that guy over there did it. Not that doctors are that casual about it, but still, you know, they also want to, they wanna treat you, they wanna help you, and they wanna make this right, but sometimes they're going a little bit outside the realm of what's considered standard, which is fine. But then it's your responsibility to say, how far out there are we going? Oh, well this is purely experimental. They just came out with this in Canada last week.

Joyce Griggs: Mm-hmm.

Jordan Shields: And so is it FDA approved? Well, no, it's being investigated, which, and as soon as they say that, you know, I'm paying for it. Now that doesn't mean you won't. Take for example, you know, ALS, I mean a horrible disease. They've come out with a new medication. The FDA barely approved it, but they did approve it. But even before that, it was being prescribed and ALS patients who don't have a lot of other medications they can take, were saying, I'll do it and they were paying for it. The insurance company's like, not a chance. Then the FDA approved it. Now we don't have to do all the peer review and all that. All of a sudden it's like, this drug is good. So when you see them drift, when you see the eyes go here, when they go well, and their shoulders start moving, you know, to ask the question, what do I need to know to get this thing taken care of in advance.

Joyce Griggs: Right, in advance. That's key because besides what's available through your insurance company, we're getting in a little bit of different realm here, but for things that are investigational or experimental or not yet approved, there is compassionate use. Sometimes that's allowed by the FDA and there's also the drug companies themselves offering opportunities, right, to help pay for these and to freight costs and things like that. So it's important. If you're in a situation like that, and we're talking about some very specific rare incidences or just where there aren't a lot of options, it's important to, I guess, chase down all the opportunities.

Jordan Shields: And back to what we said about specialists before, while your general practitioner or your internist may not be familiar with all the opportunities available with this thing, specialists often are because this is what they're dealing with.

Joyce Griggs: Yeah.

Jordan Shields: And they know that they're dealing with experimental investigational, and they already have the names of the drug companies or the the local foundations or the grant makers or whatever that will make this available. So they, they are well versed. Maybe not the doctor, but as you said earlier, Joyce, their staff usually knows quite well.

Joyce Griggs: Yeah. So let's talk about what are some of the examples of medical necessity? We've talked about procedures, we've talked about drugs. What about like hospital stays or rehabs or like, what are some other examples that we should think about?

Alan Feren, M.D.: I think a good example is the medical stay. And that is called " length of stay guidelines."

One thing that I'd like to augment first though, is that in today's society, a lot is brought in from Dr. Google, and so doctors have to deal with patients coming in and saying, what about this? I read about that study or this person had this procedure. And I think that's actually more often the case today than it was back in the days when I was a practitioner. People were just starting to bring in information from Dr. Google and asking about it. And it's a time suck for physicians and I really empathize with that aspect.

And going back to length of stay guidelines. If you look over the years, really starting back in the late seventies and early eighties, something called "managed care" popped up. And managed care looked very carefully at how long patients needed to stay in a hospital to recover adequately from whatever they were hospitalized for, whatever medical condition.

And there were tremendous differences between areas in the US, actually California had one of the shortest length of stay on average for many procedures and medical conditions. And what the carriers are interested in is that patients have recovered to the extent that they can be moved either out of the hospital and to a home environment or to a, what's called a lower level of care. It's not that the care is low, but it's not of the same intensity. So like a skilled nursing unit, SNF as it's referred to Skilled Nursing Facility. People who have had a stroke can be moved safely into that where they're don't require nursing 24 7. And they also have all the resources that are necessary for rehabilitation.

It was very interesting back in the mid eighties when we began looking at length of stay and seeing the differences where someone would come in. Let's talk about knee surgery. Knee surgery used to be a 7 to 10 day inpatient length of stay. Now

Jordan Shields: More like seven to 10 hours.

Alan Feren, M.D.: Yeah. And now it's even being done safely as an outpatient, if you can believe. So there are lots of things that have been done to speed up. You don't wanna be in a hospital unless you're sick and there are issues.

Jordan Shields: And even then.

Alan Feren, M.D.: Yeah, to long hospitalizations and in any hospitalization, including infection, medical errors. So you, you wanna be in a place where it's safe for you to be. At home is often one of the best places for care, providing that you have the resources available.

You can get a letter, if you say, you know, you just wanna linger in the hospital, you needed one extra day.

Joyce Griggs: Right.

Alan Feren, M.D.: You're gonna be denied because if your vital signs are stable and if you're eating and you don't have a fever and whatever lab is necessary is trending towards normal or is normal, it's time to leave the facility.

Jordan Shields: But back to the prevention, when you know you're going to go in the hospital, it's a good idea to ask your doctor's office, how many days am I authorized to stay in the hospital? Because they were supposed to call in advance and check, or the hospital is supposed to call in advance and check, and this is especially true with Medicare. So if they say two days and now it's the second day, and the doctor said, well, I think you need to stay another day because you got a complication, there's whatever it might be, have you guys called and made sure that I'm authorized for the extra day?

As a patient, this shouldn't be your job. Right? But as a payor, it is your job and if you don't do your job and they don't do theirs, you're the one that gets stuck with the bill. So it's always good to just have a, a brief checklist. These are the things I need to know on there or you hand it to your partner or you know your child and say, make sure you ask them this, because I have to stay an extra day.

I had to stay an extra day years ago when I had yet another knee surgery. And the reason that they had me stay one more night, and I didn't wanna be there, was because the physical therapy person didn't have a chance to get around to me to show me how to walk down the stairs. I said, I already know how to walk down the stairs. I'm leaving. I said, tell you what, you call the carrier, see if I'm authorized for another day. Well, I wasn't. Bye-bye.

Joyce Griggs: Right.

Jordan Shields: I said, I dunno who you think is paying for it, but I'm not. I'm leaving and I will, I'll crawl down the stairs. I wanna get outta here. I, of course, am everyone's favorite, you know, patient and the world's worst nightmare. It's like, no, we're gonna do it this way, we're gonna do it that, but because I know. And I don't trust anybody to get it right, because I have to be my own best advocate. Not that the carers are trying to burn me, not that the hospital's trying to burn me. They don't get it, and they got a lot of other things to worry about. I can only worry about me, so I have to be my own best advocate.

Alan Feren, M.D.: Well, the good news really is that health plans today will send you a letter of, of authorization and, and you'll know right up front.

Jordan Shields: Most of the time.

Joyce Griggs: Make sure you get that. Mm-hmm.

Jordan Shields: Yes.

Joyce Griggs: I have a question for you. Kind of a different scenario. Like, you were ready to go home, Jordan, and you knew what to do, but there are situations like, joint replacement, and then there's the opportunity to either go immediately home or in some cases you might be sent to a rehab facility for five days.

But if that depends on how you're doing at that point. If the family feels and you have valid reasons that that loved one should be going to a rehab facility because it's not safe for them at home, how do we advocate for ourselves within the system to try to get that authorized in advance or when we're in the hospital, like what happens? What can we do?

Alan Feren, M.D.: Is your question to be authorized to go to rehab?

Joyce Griggs: Yeah.

Alan Feren, M.D.: Well, social services plays a very important role in this and in conjunction with your physician. It has to be safe for you to go, whether it's home or whether it's to rehab, and your orthopedic surgeon or proceduralist can contact the insurance company and discuss what's the best avenue for the patient.

Joyce Griggs: Mm-hmm. Mm-hmm.

Jordan Shields: It's gonna be ify you though, because if you're saying, look, I got small kids at home and it's not safe, and they might knock my crutches out from under me, you know that's a good common sense approach. Now, I'm the insurance carrier. Well, hold on, let me get this straight. You're telling me you can't control your kids, so I have to go ahead and spend 500 bucks a day for you to go somewhere and be on a vacation.

It's not what they really think, but you have to understand there's a dichotomy of thought on this. And even though your doctor may say, and your partner may say and, and you say, it would be safer for me to be in rehab, the carrier will most likely say, no, it's not necessary. You haven't proven to me that it's medically required.

Again, we're at medical necessity, not family necessity, not general common sense necessity.

Joyce Griggs: Right.

Jordan Shields: So when the carrier's gonna turn you down on that in advance, you're pretty sure that it's gonna be turned down going forward. You don't usually have a good reason.

Joyce Griggs: What about an example of a good basis if it's unsafe in the home. I mean something like somebody's going home alone.

Jordan Shields: That that would be more, more appropriate. But then they could say, well, instead of you going to a rehab facility, we're gonna have a home healthcare nurse.

Joyce Griggs: Mm-hmm. Mm-hmm.

Jordan Shields: Because you don't need someone staying overnight, but you do need someone during the day to help you with this. Well, that's a lot less. So they may compromise with you and say, well, you can't go home, but we're not sending you to rehab, so let's do the nurse thing. And that's fine. You have visiting nurse associations, home healthcare nursing, staffing agencies all over the place. And that's fine.

Joyce Griggs: Mm-hmm. Okay. It's just important, right, in these situations to really think things through and work with your, if it's a surgery, for example, work with your surgeon to kind of go through everything that your concerns might be and the surgical coordinator to work through these things with your carrier and with them in advance. Because I don't think we think about these things until all of a sudden you're confronted with, oh, now I have to go home. And maybe it's not gonna work out for me for whatever your reasons might, might be. So it's just important to think about these things when you're still, you know, have your wits about you, so to speak, right?

Jordan Shields: Or that somebody else has their wits about them. If you're gonna go in the hospital, let's say you're, you're not married, you don't have a significant other, if you've got a good friend, have them help you with it just so you've got someone who's not on anesthesia, not on medication, who can think clearly and say, you know, I know Jordan's babbling about whatever right now, but that's my usual state. But I need to say, what about this? What about that? How are we gonna advocate?

I'll give you a quick example, the reverse one too, where somebody wanted to exceed an average length of stay. This is where it gets cruel. We had a client whose father was dying in the hospital. He was gonna die. He was gonna die very soon. But Medicare length of stay guidelines said we've treated him for everything we can in the hospital. We're sending him home. It was safe to send him home. It was okay to send him home. The problem is, is the client told me that means my mother gets to watch my father die at home. I'd rather he die in the hospital. And I said, I'm sorry. But the Medicare length of stay guidelines are, he's going home because there's no treatment being provided here.

That was cruel. It was vicious, but it was also "correct." He understood, he didn't like it. But then I showed him how to work out a deal with the hospital. Listen, tell you what, you got some empty beds. I'll pay you half rate, let him stay, and that's exactly what they did. And he died there two days later.

So again, there's always some sort of compromise. It can't all be on the insurance company, it can't all be on Medicare, but sometimes there are private pay options that you can exercise.

Joyce Griggs: Mm-hmm. Right. I think that's the key here, right? Try to understand your options.

Jordan Shields: Yes.

Joyce Griggs: So before we wrap up, cause this has been amazing.

Jordan Shields: I thought we're just getting started. Wait, wait, there's more.

Joyce Griggs: Wait, there's more. There's more. We're gonna have more segments. I'm so excited for that. What about anything we've left out that we haven't spoken about in terms of medical necessity before I let one of you just kind of summarize the key points.

Alan Feren, M.D.: I think that drug use is another important area. And, as we know, the so-called drug list or what health plans refer to as "formularies" create a lot of friction with patients and each year the formulary changes, the drug list changes, and there are lots of things to talk about that relate to that issue. But it's important to understand that there is a pharmacy and therapeutics committee, just like the medical policy committees at health plans that determine the safety and effectiveness of particular drugs. And then they have a formulary that determines what drugs are covered and at what level coverage, and we'll go into that in some significant detail at a later date.

Jordan Shields: We can spend 45 minutes doing that one alone. Yeah.

Alan Feren, M.D.: Yeah. I think the key words here are step therapy, and that is that based upon the formulary, you may be asked to try a particular drug first, and it has to fail before they'll allow a different drug to be used. And sometimes they'll allow for a non-formulary drug to be used when you've gone through all the things that they have suggested you use. But it's a source of irritation and frustration with patients.

Joyce Griggs: Yeah, it's very important. And I think the other thing to mention on that in terms of medical necessity is if you are hospitalized and they change your medications, make sure that you ask that the medications they're putting you on are covered by your insurance plan. Because sometimes in the hospital, I've seen it happen in my own experience, being released on a drug that is not covered by my plan.

Jordan Shields: I have two things to say. Trust no one and get it in writing. That's it. If you, if you can do those two things, you are well on your way to having a, a fun time with the insurance company.

Joyce Griggs: Yeah. No, I think that's right. So what's our wrap up here on medical necessity?

Jordan Shields: Trust us. Oh, sorry. No, that was it. Trust no one and get it in writing.

Joyce Griggs: And get it in writing. And medical necessity, it's something that's established by the insurance providers. It's based on evidence. It's not just based on what they wanna pay for, what they don't wanna pay for.

Jordan Shields: But the other thing, and Alan I know has mentioned this before in some of his, you know, materials: don't panic. Not medically necessarily? Oh my God. Hold, hold on a second. That was just their first shot at it. Insurance companies are very good at reacting and not necessarily acting, which they should cuz they get a lot of claims per day. You know, pity the poor examiner. They got all this stuff coming across their desk. They want to get it off their desk as quickly as possible, as they should. As as a supervisor, I would want them to have some rapid movement. So sometimes the statement, you know, not medically necessary and all that is just a convenient way to push back at you and say, I need more information. That's what they should be saying, but they don't. So your first reaction is, oh my God, it's not covered. No, it's, oh shoot. I gotta provide more information. Ratchet it down, calm down. Talk to your office manager, HR manager, your insurance broker, outside medical expert, anyone who can be rational about your care, your doctor's office, and say, what's my next step? That's what we're providing with these, you know, tutorials and that's what we provide on our website, information about how to do that. But a lot of people know it. So find that.

Alan Feren, M.D.: So I would summarize and just say, be prepared and plan ahead. When something has been determined to be not medically necessary, it's usually a lower level person looking for some specific thing that the health plan has guidelines before it is sent up to other levels of evaluation. As Jordan said, and I absolutely agree, don't knee jerk initially when you get a denial because of not being medically necessary.

Joyce Griggs: Mm-hmm. That's great. That's really important advice. And of course what we're talking about is doing this in a preventative way, not going and having a procedure and then finding out it's not covered, but instead putting in your paperwork, finding out if it is covered. If you get a letter back that says it's not considered medically necessary, then you just move on to the next step and we're gonna show you how you can do that.

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