A medical emergency leaves you with tens of thousands of dollars in unpaid hospital bills. Your health insurance company rejects coverage for an important medical test. An unexpected diagnosis requires you to find three new medical specialists.
In today's health care system, consumers are increasingly on their own when these complex -- and often costly -- medical problems arise. Primary care doctors once helped patients manage such situations, but many physicians now have 15 minutes or less for each appointment. It's in this high-pressure environment that a new industry of patient advocates -- sometimes called patient navigators -- has emerged, offering to help guide patients through knotty health situations.
Driven by an increasing number of baby boomers dealing with chronic medical problems, the field has mainly taken shape in the last 5 to 10 years, according to Professor Theresa Cronan of San Diego State University.
"People with chronic conditions use the health care system more. But the health care system has become so complex that it's really hard for people to navigate," said Cronan, who has studied the health advocacy industry.
Here are some questions and answers about these businesses and the services they offer:
1. What do patient advocates do?
Patient advocates are hired to help solve health care problems or help patients get the best care possible. Advocates can work for companies with hundreds of employees or operate as stand-alone consultants for a handful of clients. Some of the most common tasks health advocates work on include:
— Negotiating discounts and payment plans for large medical bills;
— Managing and filing insurance paperwork, especially appeals where companies deny coverage for expensive procedures or equipment;
— Helping patients find and schedule appointments with medical experts who specialize in rare or hard-to-treat diseases.
2. How can these businesses potentially save me money?
Many patient advocates highlight their ability to help reduce medical bills or cut through insurance red tape.
Health advocates can review patient records to spot billing errors that drive up costs. They can also coordinate care between a number of physicians, usually for patients with complex conditions, avoiding repeat billings and insurance payments.
In other cases, advocates will help patients find the best price for an expensive test or procedures. Prices for common tests, such as medical scans, can vary by hundreds or thousands of dollars, even among hospitals that are only a few miles apart, as demonstrated by payment records released by the government's Medicare program. With many patients in high-deductible insurance plans that require them to pay substantial out of pocket costs before coverage kicks in, the difference between a $300 MRI scan or a $1,300 MRI scan can be significant.
3. How much do these services cost?
Patient advocates typically aren't covered by insurance, so customers should expect to pay out of pocket.
Many charge an hourly rate, ranging from $50 to $250 depending on the nature of the work, their location and background. Advocates charging the highest fees usually have a medical degree. Other services may use alternative fee structures. For instance, the medical bill saver service offered by Health Advocates of Plymouth Meeting, Pennsylvania negotiates uncovered medical or dental bills of $400 or more at no upfront cost to the customer. Instead, the company takes a 25 percent cut of the recouped savings. So if the company negotiated a $10,000 medical bill down to $5,000 the company would earn a $1,250 fee. Health Advocates sells access to its bill saver service and other offerings through an annual membership fee of $25.95. About 50,000 companies also offer Health Advocates' services as a benefit to their employees.
4. What qualifications do patient advocates need to have?
Currently there are no professional credentials required to be a patient advocate, so be careful about choosing a service. Several universities offer specialized courses and degrees in patient advocacy, including Sarah Lawrence College, the University of Miami and the University of Wisconsin. Such programs often combine training in medicine, health policy, economics and law. Other health advocates have backgrounds in nursing, social work, medicine and the insurance industry.
Before hiring a health advocate be sure to ask for references and information on training and experience. Customers should also receive a written contract specifying the services to be delivered and the fees.
"If you're going to get a health care advocate you're probably feeling vulnerable already, so you want to make sure you look very carefully at the organization that is going to provide these services," Cronan said.
5. How can I find a patient advocate?
Academic programs like University of Wisconsin's Center for Patient Partnerships can provide contact information for graduates in the field. There are also several professional groups that offer online search tools for finding patient advocates, including:
— National Association of Healthcare Advocacy, which requires members to sign a code of ethics: http://www.nahac.com
— Alliance of Professional Health Advocates, which requires participants to have professional liability insurance: http://www.advoconnection.com/