health advocacy

Choosing Your Health Care Advocate

Going it alone is NEVER the best choice when it comes to health care. Especially if you have time-sensitive treatments, a complicated diagnosis, or insurance issues to consider. When you need someone on your side — supporting your well-being, getting medical appointments, managing treatments plans or fighting for your benefit rights — you need a health advocate.

A relatively new response to today’s complicated health care system, health advocacy is considered a critical service by CNN and other news sources. Knowing when to hire an advocate, and how to choose one that’s right for you, is key to a successful outcome.

What’s the Problem?

Define your needs before looking for someone to help resolve issues. For example:

Do you need someone to oversee care being provided to yourself or a loved one?
Are your needs related to developing a plan of care for a particular diagnosis?
Is it an insurance issue? Are your benefits being denied?
Do you need help researching the latest technologies and treatments for a disease?
Are you worried about mom and dad living alone?
Will you need the advocate to be onsite at a hospital or facility?

Locating a Private Advocate

An internet search, using the key words “health care advocate” will direct you to advocate websites. Review their areas of expertise; narrow your choices and examine how their services meet your defined needs. Ask for referrals from friends, family members and physicians (use the terminology “case manager”).

Consider the Fit

Like physicians and health problems, advocates come in all shapes and sizes. Some have a “take charge” style” others are more laid back. Finding the right fit is critical. Things to consider:

Have they helped clients with similar issues?
If so, what do they consider a successful outcome?
How many client cases do they work on at the same time?
Do they have a resource network?
How easily can you reach them during the week? Off hours? Holidays?
How do they keep clients apprised of progress?
How does the advocate charge for services: hourly or set rate?

Health advocacy is typically private pay, with fees ranging from $100 – $200/hour. The right advocate will guide you through the health care maze and so that you get the benefits and treatments you need when you need them. And that’s priceless.

Is this an Emergency?

There are times when you know it’s an emergency and you’re off to the ER. You don’t fool around with chest pains, for instance (no taking chances that it’s just indigestion). Ditto for broken bones and deep cuts.

But what about those other times? You know them: the sense that something’s wrong, but you’re not sure how bad it really is. it always seems to happen over a weekend or during the evening, when the doctor’s office is closed. Waiting doesn’t feel right, but neither does rushing to the emergency room.

Call your doctor. Most physicians have an answering service for this purpose. Offer the following:

Your full name; that you’re a current patient, in active treatment.
The best way to reach you (provide both cell number and land line).
The reason for your call, emphasizing that, while it doesn’t seem like an emergency, it’s a matter of serious concern that can’t wait for office hours. Don’t be too explicit, as most folks who take messages have little clinical experience. Use phrases, such as:
- My new medication is making me ill
- I am experiencing several new symptoms
- My pain has increased over the last (number of) hours and I need to discuss a different approach

Find out who’s on call. Ask the service to contact the doctor on your behalf rather than waiting for him/her to call in for messages. Note the time of your call and ask to be called back after the service relays your concerns. This will give you a time frame and help relieve anxiety.

Don’t ever hesitate to seek help. Even over a weekend. Even when you’re not sure whether or not it’s an emergency.

Where’s Common Sense When You Need It?

We’re offering a friendly challenge to the CEO’s of all health plans: leave your corner office and walk a mile in the shoes of people covered by your plan. What do you see? What touches your heart? What are you doing right? And what needs fixing? Notice a common theme in your walkabout: a lack of plain old common sense.

Here’s a case-in-point from an experience with Oxford, as we attempted to help our client through the health care maze. She engaged our services, signed a HIPAA form, as well as a form authorizing Health Champion as her representative. Because many health plans have their own authorization forms (wouldn’t standardization be in everyone’s best interests?), we immediately contacted Oxford. Here’s what ensued in our dealings with customer service:

O: Reading from the computer screen (no thinking necessary!): the completed form must be mailed to Oxford at their Bridgeport, CT address.

HC: Our client needs immediate help. Can we scan the signed form and email it?

O: No.

HC: Can we fax it?

O: No.

HC: If we overnight it, how long before the information becomes available to customer service reps?

O: About a month.

HC: Is there someway to move this along?

O: Nope.

HC: Our client needs help now. Isn’t there something we can do?

O: Well, you could get her on the phone with you, call in together so that she gives permission for the rep to answer your questions.

And you didn’t tell us that upfront?

We did just that. Our list of questions was long and the customer service rep was ill prepared to answer them, frequently placing us on hold to check with someone or something (a manual?). We reached the end of a long business day and our client was fading (remember, she’s dealing with health issues).

HC: Let’s finish this tomorrow. Can you note in the system that we received permission to speak to Oxford; can we continue the call in the morning without having to get our client back on the phone?

O: No.

HC: Why not?

O: We can’t do that. We are only allowed to get verbal approval for one call.

HC: But the call isn’t finished.

O: Sorry we can’t do that. The federal law, HIPAA, prevents us from doing that.

Since when? (When in doubt, quote the federal law, even if you’re wrong!) Now, there’s common sense in play!

CEO’s: are you paying attention? While health and clinical services are critical to accreditation from the National Committee on Quality Assurance, we suggest that, a common sense standard is just as critical.

Your thoughts? Post your experiences, comments and insights.

We’re New And We’re Here to Stay

“You’re a WHAT? And you do WHAT?”

It’s a typical a response from physicians who haven’t scanned the forest of health care lately to see there’s a new animal in their midst. That animal goes by the general name of “health care advocate” and the specific name of Health Champion. Our general nature is to help, guide and support individuals lost in the maze of decisions, diagnosis and insurance benefits.

Here’s an example —

The Call: We were recently retained by a family to help navigate their sister’s s journey through multiple myeloma. They called as she was recovering from surgery, having experienced the disease’s wrath in the form of bony metastases.

The Need: On a very basic level, they were seeking clarity about their sister’s condition, needing a greater understanding from the surgeon and oncologist regarding prognosis and overall treatment plan.

The Approach: We quickly established contact with their sister’s medical providers, providing each office with signed HIPAA and Representative forms, so that physicians could speak freely with us. The goal was to collect information from the various sources and then connect the dots for our client, explaining complicated information in a clear, accessible manner.

The Result: Our client and her family felt fully informed and, thereby, empowered to make smart decisions regarding the recommended treatment plan.

The Response: Because we’re newcomers, medical colleagues are often surprised by our presence. Who are we . . .where did we come from . . . what’s our intention? But, seeing that we come in peace, they’re collaborative, professional and open to the concept of advocacy. And then there are those few defensive physicians, wary of our intentions, certain our goal is to undermine and undercut, to add an unneeded layer to an already complex system. That is so not so!

They’re right about one thing: The health care system is definitely layered and complex. It’s fragmented, confusing and overwhelming. It isn’t easy being a physician in today’s insurance-based model. And it’s not easy being a patient or consumer. That’s exactly why we exist.

Our role is to support our clients and their health care team by closing gaps in communication and planning, by explaining and reinforcing the difficult messages they have may have been told, but didn’t understand, and were too embarrassed to ask for clarification.

While health care reform may be upon us, it isn’t going to fix the very things that health care advocates are hired to do. We’re on the scene, and we’re here to stay.

The Test Gets Authorized

“Why won’t my insurance cover a CT Scan of my heart that the doctor says I need.”

That was the call we received recently from a woman who was confused, upset, and uncertain about getting the care she needed. She’d had questionable results from both her stress test and her cardiologist recommended that she follow up with a CT scan ( to be exact, her doc wanted a CT scan of her coronary arteries, affectionately known as code 0146T).

But her insurance company refused to authorize this critical test.

Why? Was there anything we could do to help?

We went right to work and here’s what we discovered:

The cardiologist’s office followed protocol by calling the woman’s health plan and submitting the required information. However, what was submitted didn’t meet her insurance guidelines.
We obtained a copy of the company’s guidelines for radiology, and then compared the information sent by the doctor.
We then interviewed the woman and discovered she’d neglected to mention certain symptoms to her doctor.
We discussed those symptoms with the doctor’s office; they updated the information, sent it off for insurance review, and the test was authorized.

Lessons learned…

Always ask why. If you need a test/procedure and your health plan won’t authorize it, ask for clarification. You’re entitled to a copy of the guidelines used to make the decision.
Don’t assume that your doctor’s office will engage with the health plan on your behalf. Stay on top of the situation.
Review the information and symptoms you’ve shared with your doctor and see if there’s more that might be helpful.
If you’re having trouble getting answers, enlist help. Don’t just settle for “no.”
Realize that by enlisting a private advocate, you save time and money and get results.

Health Champion Blog

"In Your Corner"

Choosing Your Health Care Advocate

Is this an Emergency?

Where’s Common Sense When You Need It?

We’re New And We’re Here to Stay

The Test Gets Authorized

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