As doctors, we are skilled in knowing what diagnostic tests are needed to determine what is causing a patient’s symptoms. We also know what the best treatment is. Often, some options may be equally effective, and we educate patients to make informed treatment plan decisions. While a doctor and patient may agree that a given course is medically necessary, that doesn’t mean the payer agrees.

Every day, a plan (either a diagnostic test or medication) that was formulated with a patient after a discussion is destroyed when the payer overturns that medical decision. Payers now have medication formularies that they cover—and they are becoming narrower every year. Often, a medication is prescribed and the payer does not cover any medication in that class. A steroid inhaler for asthma is not the same as a long-acting beta-agonists, yet some insurance companies want doctors to try a steroid inhaler first. A patient may be well-controlled on a medication for years, but the insurance company doesn’t care if their formulary changes.

Payers often deny services for diagnostic tests, procedures, hospitalization, and other medical services. To deny treatment, they often cite the service was not medically necessary. Were the services reviewed by a medical expert to determine if a patient needs these medical services? No, they were evaluated by a series of guidelines to follow a certain clinical pathway that was devised, not by doctors, but by payers. Are these guidelines evidence-based? They do incorporate some evidence into their guidelines but their data is outdated. Its chief aim is cost-containment rather than clinical outcome. Most often, their guidelines are not transparent to clinicians or patients—we often wonder why a service is not deemed “medically necessary.”

Healthcare is becoming increasingly more complex and patients have to do more to navigate the system. However, when payers default to denying services based on a vague, loose definition of medical necessity, there is no way this can be solved. I need to provide the services my patients need to determine what may be wrong with them. Also, if my patient needs a medication, they need a medication. Their lives and well-being are at stake. When a patient has to wait days getting a life-saving medication while the payers play with their definitions, we have lost the essence of medical care. Medical necessity needs to return to its roots and be about good clinical outcomes—not driving up profits for big corporations.

  • Linda Girgis, MD, FAAFP

    Linda Girgis, MD, FAAFP, is Owner of Girgis Family Medicine LLC. Currently affiliated with St. Peter’s University Hospital and Raritan Bay Hospital, Linda also writes for Sermo, Physician’s Weekly, the Library of Medicine, and others.

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