Patient Advocacy: Healthcare on your side

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse, 

Healthcare Specialist, Patient Advocate, Certified Mediator

ADVIMEDPRO

Five Good Reasons to Hire 
                                       a Patient Advocate 

A growing field in the healthcare industry is that of Patient Advocacy. Though still in its toddlerhood, this profession is starting to spread its message of expertise, service and problem solving to an expanding base of patients. Disclaimer: I am an advocate, providing advocacy, account management, mediation and consulting services. 

You may have noticed that insurance companies, philanthropic patient support associations, hospitals as well as governmental agencies and healthcare organizations are now offering the services of advocates to their patients. 

   
 By all means, use these services when offered to you, usually free. These intermediaries will assist you with financial assistance applications, with navigating their hospital or place of medical care, with providing you with information and support when faced with a serious diagnosis or upcoming treatment, with grievance advise against your insurer. 

These services are however, limited to the advocate's employer. Their scope of service, while beneficial and most helpful, remains confined to a restricted area. 

Here are 5 good reasons to consider for hiring your own patient advocate. 

1. This system is too confusing

  We all find the healthcare system confusing and too complex.

 To learn the system now will require learning some medicine, medical coding, legal requirements, specific insurance guidelines, the Alphabet soup of terms, the art of mediation, your rights, your state and carrier grievance processes, patient assistance and support opportunities with a dash of common sense, a bag of tenacity and ongoing deliveries of patience. 

     A good patient advocate can help you now either fight the system or take advantage of it, depending on your view of the water in the glass. Need someone to explain your insurance benefits? Cannot understand where to turn, who to ask or what your next step is? Need basic information, more education on your rights,  specific material? Need a helping and guiding hand that is on your side? Consider hiring a patient advocate.

2. You need to concentrate on my health and recovery

   When life throws you or a loved one a challenge, your time, attention, energy and resources will be focused on going through the process of reaching a positive outcome. From the serious aspects of a upcoming treatment, surgery, or event to the day-to-day affair of living, you are stretched thin. The financial, emotional, physical, practical and spiritual toll is often overwhelming and life-altering. 

   Hiring an advocate can put assets on your side from the beginning. Working with your medical providers, he/she can verify your coverage, benefits and authorization status, and whether a treatment is standard and established. The advocate can also negotiate reduced fees or a payment plan, help find assistance and make sure you are getting the services you need and that are covered. Some advocates will take you to appointments, advise you on specialized care and facilities, or research treatments and options. 

3. I am not sure what and who to pay

    The easy answer is to match your EOBs to your statements. But this won't help you if they don't, or if a mistake was made. where did it originate? how to correct it? Your advocate will audit your bills as they come in, analyze statements and EOBs, and advise you on paying a bill or file an appeal.

4. My insurance is not paying my claims

   What is the reason? There should be a good explanation as to why an insurer would reject a claim. If you do not have the time, knowledge or inclination to hear one person throw the blame at another with no resolution in sight and growing frustration, let your patient advocate handle the job. Errors will be rectified, records sent, appeals filed and sanity restored. 

5. I cannot pay these bills

   Let me first remind everyone that checking coverage and benefits, getting authorizations and assessing one's likely liability should be done before a treatment or procedure. Preparation is key. But too often we are dealt circumstances out of our control which, added to a lack of understanding of policies and guidelines and an inflexible and uncaring system, lead us to hopeless situations. A patient advocate's expertise and skills may well find overcharged, erroneous or non billable charges. He/she may find ways to appeal for additional benefits or help you get approved for assistance or reduced fees. At least can he/she negotiate on your behalf, arrange for a payment plan or a reduction of your liability. 

A word of caution: 

At this time, it is necessary to point out that not all advocates are created equal. Services, skills and credentials vary from the well-seasoned and experienced to the newly minted and self proclaimed. 

There is no federal or State accreditation process. There are no "official" credentials, certifications or degrees.   There currently are no regulations.

Courses, training opportunities and "certifications" are now offered by a few colleges, associations and  trade schools. While some training and education are better than none, the complexity of today's healthcare machine, the scope of patients' needs and the vast range of required skills and knowledge make it a challenge for novices. Experience in this field, especially specialized, is a must. Ask for credentials based on verifiable resume contents and letters of recommendation, or ask for a referral from knowledgeable and trustworthy sources.

			©  [2016] Advimedpro. ©  [2016] Martine G. Brousse. All rights reserved. My objective is to offer you, the patient, concrete and beneficial information, useful tips, proven and efficient tools as well as trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements.  AdvimedPro        (424) 999 4705 or (877) 658 9446       fax (424) 226 1330                                          www.advimedpro.com           contact@advimedpro.com

Patient Advocacy: Healthcare on your side issue 2

                                                                                                                                      

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse, 

Healthcare Specialist, Patient Advocate, Certified Mediator

ADVIMEDPRO

The question never to ask a medical provider

"Do you take my insurance card?"
By asking this seemingly benign question, and being told "yes we do", you, the patient, have just started a game of chance in which you have placed your financial future in the hands of medical staff members without being given the rules.

Your Doctorʻs staff means: "Great! We'll take your card to make a copy. You have some kind of insurance, itʻs your responsibility to know what is is, someone will pay us and what is not paid, we'll bill you for it". 

You actually meant: "I have some kind of insurance. I trust and expect you to understand it, will deal with it and will get paid by it while I focus on my health with little further responsibility". 

Here are the 3 mistakes you made: 

A. Not knowing your basic insurance coverage

I understand, the alphabet soup and complex terms mean nothing to you, and you have neither inclination not time nor energy for it. But you should know which one of the 3 basic types of coverage your coverage falls under. Your card should indicate the letters or name you need. See "question of the day" below for details. 

B. Blindly trusting the medical office staff

You assume and trust that the people who work for your doctor are: caring, trained, knowledgeable, and have taken care of all the necessary details. In a perfect world, and in many offices, this is the case. However, in these days of overworked, overwhelmed and oftentimes untrained personnel, consider this: no one wants to turn you away even though the office is not part of your insurance network, no one wants to tell the Dr a significant appointment spot was erroneously scheduled then wasted on a patient who was turned away, no one checked coverage beforehand, no one had your correct insurance info, no one bothered to get an authorization, there is no time to get an authorization now that you have provided insurance info, no one cares at the front desk as it will be the Billing departmentʻs problem down the line. See where Iʻm going? Chances are the office will still get paid something, the difference is how much you will be taken to the cleaners for. 

It is your responsibility to make sure (1) the office has the correct insurance info (2) the necessary authorization is on file (3) the provider is contracted and "in network".

C. Not understanding that you probably do have some kind of financial responsibility. 

Unless you have the extreme good fortune to have some type of coverage that covers you at 100%, the odds are that you will owe something to someone. Even Medicare patients have a yearly deductible. Knowing what to expect can help you plan better, lower your anxiety at unexpected "surprises", negotiate payment plans or look for financial assistance. 

Patients are usually be responsible for:

- yearly Deductible: the amount the patient pays first before an insurance issues reimbursement

- Out of Pocket: after the deductible is met by you, the insurance rarely pays 100%. They will pay a % (indicated in your policy) and you will pay the difference up to a certain amount. After that OOP has been met, then will your claims be paid at 100%.

- Office Copay: many plans impose a set amount per office visit, whether you see the Dr or  not. This copay will be requested by and is owed to medical office at the time of your visit. 

Note: if using non contracted providers ("Out of network"), your cost will likely skyrocket. Expect your Deductible and OOP to double, and your insurance reimbursement rate and payment to be much lower. You will also be responsible for any sum between the amount billed by the provider and the allowed amount by your insurance. Never use a non  contracted provider unless absolutely necessary. If you must, NEVER receive services before negotiating the fees ahead of time.

In conclusion, these are the 3 major reasons why your conversation with your medical providerʻs office should run something like that:

" I have --- (name type of coverage like PPO or HMO) with ---- (name insurance)

Is Dr Smiley a contracted provider with this insurance and plan? 

Is an authorization needed? If yes, do you already have it or should I get one? (ask who can issue it). If no, are you sure? 

What kind of cost should I expect for the services? 

Last piece of advice: record the name of the person, answers given to you and date in your files. You never know. And if the person you speak with seems evasive, uncaring or ignorant, trust your instinct and either ask for a supervisor or find another office. 

©  [2016] Advimedpro.

©  [2016] Martine G. Brousse.

All rights reserved.

My objective is to offer you, the patient, concrete and beneficial information, useful tips, proven and efficient tools as well as trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements. 

AdvimedPro        (424) 999 4705 or (877) 658 9446       fax (424) 226 1330

                                         www.advimedpro.com           contact@advimedpro.com