If you are dealing with a complicated health-insurance hassle or bill you don’t understand, you don’t have to struggle alone. One way to save yourself time and money on health-care issues is to enlist the services of a growing group of people who are experts in navigating the system.
Known as health-care or patient advocates, these consumer-assistance offices range in size and scope, so it is relatively easy to find one that fits your needs. The Affordable Care Act has provided $58 million in grants to help states establish or strengthen such offices, whose mandates include helping consumers file complaints and appeals against health plans and educating consumers about their rights.
At least 24 states and territories have taken advantage of the funding. To find out if your state runs such an office, go to the Centers for Medicare and Medicaid Serviceswebsite.
In Connecticut, where the state has run an Office of the Healthcare Advocate since 2001, consumers have saved some $50 million, according to
the state’s Healthcare Advocate. She says the office saved consumers $9.6 million last year through actions such as disputing medical bills and making insurers cover procedures previously denied as medically unnecessary.
Ms. Veltri says the office accepts about 98% of cases submitted, always at no cost to the consumer. If the dispute is minor—maybe a difference of $10—the office’s attorneys or consultants might advise patients on how to resolve the problem themselves. There are also problems that the office isn’t set up to help with, such as Social Security Disability disputes.
An example of a recent case, resolved in under a week, involved a young man who needed substance-abuse treatment. The health plan denied coverage for treatment beyond five days, leaving the family with a hefty bill. Ms. Veltri says her office got involved to overturn the denial, arguing that additional treatment was needed,and the full 28-day course of treatment was covered.
Another issue, she says, is hospital or provider bills that include so-called facility charges which can run up to $5,000. The intervention of the Healthcare Advocate has helped some patients wipe out those charges, especially if the patients weren’t notified of the charges in advance.
“We would like to be able to say to people that insurance and health care are not complicated, but they are,” says Ms. Veltri. “If you can’t figure something out and it’s an urgent medical situation, call early.”
Depending on where you live and what your problem is, another good option can be not-for-profit patient-advocate organizations unaffiliated with the state. The Patient Advocate Foundation, for example, works with people who have chronic, life-threatening or debilitating illnesses, as well as problems with insurance, job retention and medical debt. The foundation often takes on insurance appeals. The cases tend to be complicated, says
chairwoman of the group’s board. She says the foundation makes an average of 12 calls or other contacts on behalf of the patient, and that the average resolution time is 10 working days.
The group employs about 200 case managers, and services are free to patients who meet its eligibility criteria. Last year, the group says it relieved patients of more than $48 million in medical debt.
Mrs. Davenport-Ennis suggests people not wait to seek help if they are running into roadblocks. An example of a case the group might help resolve would involve a cancer patient who needs to miss work occasionally for treatment. If this patient learns that his or her work hours get reduced enough to drop below insurance-eligibility requirements, patient advocates can help resolve both the insurance and job-retention issues.
The foundation also helps identify financial options for patients struggling to meet high copayments for expensive medications.
Mrs. Davenport-Ennis suggests that patients seeking help first pinpoint what their problem is. If it’s related to job-based insurance, a first point of contact might be the HR office. If the problem is that you need a follow-up appointment after being discharged from a hospital, it might be the hospital’s navigator. Medical-debt problems might be addressed by requesting a repayment plan from the provider that the patient can adhere to.
For-profit options also exist, and it makes sense to see what’s available locally. National Patient Advocate in Plantation, Fla., can create personalized plans for problems like getting referrals, access to out-of-network treatment, and filing complicated paperwork, says the president and founder, Cathy F. Bowers. She says hourly rates range from about $55 to $250.