Pa­tient ad­vo­cacy takes off

More peo­ple seek help deal­ing with doc­tors, hos­pi­tals and in­sur­ers

Los Angeles Times - - MONDAY BUSINESS - By Lisa Zamosky health­care@la­times.com Twit­ter: @lisazamosky Zamosky is the au­thor of “Health­care, In­sur­ance, and You: The Savvy Con­sumer’s Guide.”

Nav­i­gat­ing the murky wa­ters of hos­pi­tal bills, in­sur­ance state­ments and med­i­cal claims can be jar­ring.

When Thomas Fe­fer’s wife of 22 years was di­ag­nosed with pan­cre­atic can­cer last sum­mer and died just 66 days later, the on­slaught of bills and bu­reau­cratic hur­dles was over­whelm­ing for him.

“The things I was sud­denly fac­ing upon her death were truly in­sur­mount­able for me to con­sider,” says Fe­fer, 63, a direc­tor for the TriCounty Bet­ter Busi­ness Bureau in Santa Bar­bara. “An ex­tra­or­di­nary num­ber of ex­penses were pil­ing up.”

He needed help. An on­line search led him to a lit­tle­known in­dus­try of pa­tient ad­vo­cates and billing spe­cial­ists that pro­vide guid­ance on deal­ing with doc­tors, hos­pi­tals and in­sur­ance com­pa­nies.

They han­dle ne­go­ti­a­tions and work to find sat­is­fac­tory billing agree­ments. Of­ten a fee is in­volved, but many em­ploy­ers will cover the cost.

“It’s about deal­ing with the sheer vol­ume of pa­per­work,” Fe­fer says. “When a fam­ily mem­ber is be­set with a ter­ri­ble ill­ness, it’s never just one bill. It’s a host of clin­ics and doc­tor and hos­pi­tals.”

Fe­fer chose Mar­tine G. Brousse, a pa­tient ad­vo­cate in Santa Mon­ica, to make sense of his wife’s med­i­cal bills.

Pro­fes­sion­als such as Brousse work with pa­tients and their fam­i­lies. They fight de­nied med­i­cal claims, file ap­peals, se­cure in­surer au­tho­riza­tion for med­i­cal care and gen­er­ally help nav­i­gate com­pli­cated in­sur­ance rules. Some help find med­i­cal care, such as spe­cial­ists and nurs­ing homes.

Th­ese pa­tient ad­vo­cates — also called med­i­cal billing ad­vo­cates or claims as­sis­tance pro­fes­sion­als — have been around for decades. But the field has taken off in re­cent years as pa­tients face higher out-of-pocket med­i­cal costs and the health­care sys­tem be­comes in­creas­ingly dif­fi­cult for the av­er­age per­son to nav­i­gate.

“Peo­ple just don’t un­der­stand what’s on their bill. The lan­guage is writ­ten in med­i­cal ter­mi­nol­ogy. Someon times clients just want a trans­la­tion,” says Mau­reen Lamb, a med­i­cal billing ad­vo­cate and chief ex­ec­u­tive of Med­i­cal Bill Sup­port in Hold­er­ness, N.H.

Larger or­ga­ni­za­tions and an es­ti­mated 300 in­de­pen­dent ad­vo­cates prac­tice na­tion­wide, ac­cord­ing to the Al­liance of Pro­fes­sional Health Ad­vo­cates, an ad­vo­cate trade group.

There is no uni­form train­ing or li­cens­ing rules for ad­vo­cates or spe­cific type of ser­vice they of­fer.

A host of or­ga­ni­za­tions pro­vide ed­u­ca­tion and sup­port to ad­vo­cate pro­fes­sion­als, many of whom are for­mer nurses, at­tor­neys or med­i­cal cod­ing pro­fes­sion­als. Some are cer­ti­fied in med­i­cal bill cod­ing by or­ga­ni­za­tions such as the Amer­i­can Academy of Pro­fes­sional Coders and the Amer­i­can Health In­for­ma­tion Man­age­ment Assn.

Pri­vate ad­vo­cates may charge by the hour, with rates rang­ing from $75 to $150. Some work on re­tainer or charge a flat project fee. An­other com­mon prac­tice is to take a per­cent­age of the sav­ings they achieve.

In­creas­ingly, em­ploy­ees have ac­cess to th­ese ser­vices the job for free as part of their work-based benefits. More than half — 52% — of em­ploy­ers with more than 500 work­ers of­fer the ser­vice, as do 27% of com­pa­nies with 10 or more em­ploy­ees, ac­cord­ing to the 2014 na­tional em­ployer health plan sur­vey by con­sult­ing firm Mercer.

The trend of pro­vid­ing work­ers ac­cess to ad­vo­cates has in­creased as high-de­ductible health plans have be­come more com­mon, says Alexander Do­maszewicz, a prin­ci­pal with Mercer.

Of­fer­ing the ben­e­fit, he says, is em­ploy­ers’ way of say­ing “We’ll give you some­one to go shoul­der-to-shoul­der with to nav­i­gate the health­care sys­tem be­cause we know it’s not easy and in­tu­itive.”

It is also a way to min­i­mize lost pro­duc­tiv­ity as em­ploy­ees spend hours at work on the phone fight­ing with their health plan or med­i­cal providers.

The re­sponse to th­ese ser­vices has gen­er­ally been pos­i­tive.

“Com­pa­nies that have im­ple­mented th­ese pro­grams have found them suc­cess­ful” among peo­ple that use them, says Shari David­son, vice pres­i­dent at Na­tional Busi­ness Group on Health, a Wash­ing­ton non­profit that rep­re­sents the health pol­icy in­ter­ests of large em­ploy­ers.

Still, the pro­fes­sion’s very ex­is­tence is a damn­ing state­ment about a health­care sys­tem so com­pli­cated that pro­fes­sion­als are needed to help peo­ple get and pay for care.

For ex­am­ple, ad­vo­cate Katalin Goencz says she rou­tinely fights on be­half of clients in need of treat­ment for men­tal health and sub­stance abuse.

“In­sur­ers rou­tinely deny them,” says Goencz, who is co-pres­i­dent of the ad­vo­cate trade group Al­liance of Claim As­sis­tance Pro­fes­sion­als in Stam­ford, Conn.

Lamb of Med­i­cal Bill Sup­port says much of her time is spent fight­ing clients’ hos­pi­tal and doc­tor bills. “They don’t know what the bills mean and how to get help. They’ve tried on their own and get the runaround,” she says.

Santa Bar­bara busi­ness­man Fe­fer is sold on the idea, say­ing work­ing with a billing ad­vo­cate def­i­nitely saved him money. In the end, though, his ad­vo­cate did so much more for him, he says. “How can you quan­tify the peace of mind that she brought me?”

Ri­cardo DeAratanha Los An­ge­les Times

THOMAS FE­FER was over­whelmed by med­i­cal bills and bu­reau­cratic hur­dles dur­ing his wife’s can­cer battle last year, so he turned to a pa­tient ad­vo­cate. “It’s about deal­ing with the sheer vol­ume of pa­per­work,” he says.

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