Medical Necessity and Medical Director Support


Medical File Reviews

  • The carrier denied a member’s coverage. Can you help us understand the rationale for that decision? 
  • „„The treatment is FDA approved. Why isn’t it covered? 
  • „„Was this denial decision consistent with what we would expect in other plans? 
  • „„This member’s treatment was denied. Are there alternative treatments that are covered? 
  • „„We need someone to get on a call with the carrier’s medical department and have a peer-to-peer conversation about this member’s denial. 

Plan Design: Clinical Perspectives

Plan design coverage is typically reassessed annually. Clients want to fully understand the advantages and costs of new coverage provisions, as well as what other employers are doing. 

New Medical Technologies and Guidelines

Clinical guidelines that impact benefits programs change frequently. Benefits leaders need to make informed decisions and advise on these matters. 

Workplace Issues

  • An employee has measles. What do we need to do?
  • „„An employee’s physician has outlined ergonomic changes to their work station. What are we required to do? 
  • „„Should we offer immunizations other than flu shots on site?
  • „„An employee has Hepatitis A. Do we have to report this to the State Department of Public Health?
  • „„An employee has a severe (life‑threatening) food allergy. What workplace precautions do we need to take?