Medical necessity—a term that seems straightforward—often becomes a complex hurdle in the world of healthcare, especially in mental health. Joe Feldman, founder of Cover My Mental Health, sheds light on the disconnect between clinical care and legal frameworks, and shares how his nonprofit empowers patients and clinicians to navigate these challenges effectively.

What is Medical Necessity?

Contrary to what many assume, "medical necessity" is not a clinical term; it’s a legal one. As Feldman explains, most healthcare professionals are trained in safe, effective care aligned with ethical standards, not in decoding the legal intricacies of medical necessity. This disconnect often leads to insurance denials, leaving patients stranded without the care they need.

Feldman highlights a key concern: insurance companies often deny claims for higher levels of care, such as intensive outpatient programs or residential treatment, by deeming them “not medically necessary.” This decision-making process frequently prioritizes cost-cutting over patient well-being.

Resources Mentioned In This Episode

• Read the full show notes here
• Use the promo code "GORDON" to get 2 months of Therapy Notes free
• Start Consulting with Gordon
• The PsychCraft Network
• The Practice of Therapy Community
• Mental Health Wear TN
• Full Focus Planner
• Cover MY Mental Health
• LinkedIn

Meet Joe Feldman

Cover My Mental Health President and Founder Joe Feldman began advocating for access to mental health care after overcoming denials for his daughter’s residential care, including with a successful federal lawsuit.

Feldman developed Cover My Mental Health based on his own success overcoming insurance obstacles, with input from leading litigators, appeals experts, clinicians, insurance regulators, and former insurance industry insiders.

His advocacy work has included policy-driven discussions with legislators and regulators, a board role with The Kennedy Forum Illinois, presentations to parent groups, and publication of actionable guidance, such as a 2021 article in the Journal of Psychiatric Practice on medical necessity letters.

Feldman also serves on the board of Thresholds, a Chicago-based firm providing support to those living with mental illness, and Acadian Kitchens, a for-profit seasonings business in Louisiana.