October 16, 2024

Have you ever had a health care service reviewed or denied by your insurance with the explanation that it wasn’t “medically necessary”? Nova’s latest Under the Coverage podcast episode dives into what medical necessity really means in the world of health insurance.

In “Unpacking the Term Medically Necessary,” two leaders from Nova’s medical management department discuss this often-misunderstood term. The broad definition of medical necessity is health care services or supplies that are considered essential for diagnosing, treating, or preventing illnesses, injuries, or medical conditions, and meet accepted standards of medical practice, according to Stefanie Watt, manager, clinical operations and guest on this episode.

“The goal here is to ensure that services or supplies are truly necessary for the patient’s medical condition and align with evidence-based standards of care for that condition,” Watt said.

Whether it’s a medication, surgery, or diagnostic imaging, all of which often require some type of review for medical necessity, it can feel to the member as if there are too many steps in the process. But those steps are intended to get to a safe result.

“Sometimes it’s just needing that additional step to get there, and it’s not meant to be red tape, but it is a checks and balances,” notes Lorene Barulich, manager, clinical programs & strategy. “So that’s why, at least here, we’re looking to work together to eliminate that as a barrier, by making sure you’re getting the care you need in the right setting at the right time, and that is the right care.”

In this insightful episode, we’ll explore:

• When health care services are reviewed for medical necessity
• Real-life examples to illustrate the decision-making process
• The appeals process and how you can challenge a determination
• Practical advice for navigating medical necessity reviews with confidence

Whether you’re a health plan member trying to understand your coverage or an industry professional seeking clarity, this episode empowers listeners with the knowledge to handle medical necessity determinations effectively.

How to Listen

New episodes – each 15 minutes or less! – are added regularly and are available on SoundCloud, Spotify, Apple Podcasts, Pandora, Amazon Music and TuneIn. You can also listen via digital assistants like Alexa, Google and Cortana. Just ask Alexa to, “play the Under the Coverage podcast on Apple Podcasts” (or wherever you get your podcasts).

Have an idea for a future episode or a question you’d like answered? Find Under the Coverage on X @UndrTheCoverage or email podcast@novahealthcare.com.