The Emerging Industry of Health Advocacy

A medical crisis is a two-part nightmare. First, there is pain and fear, doctors and hospitals, tests and surgeries. Patients and their families pass through the days in a dreamlike state, trying to understand the complicated language of medicine. Then, finally, there comes the time of recovery, when the body and mind can begin to heal.

Then the bills come, and the second part of the nightmare begins.

As the health insurance industry becomes more and more complex, and medical billing more and more complex, those who must avail themselves of medical treatment often find it impossible to navigate the systems. How do we, as consumers, know if we are being charged fairly? How can we be expected to understand the language and codes used by insurance companies and medical treatment centers? What can we do if a claim is denied, or, as in my case, we are being billed for unspecified services?

In February of 2005, my husband had what the doctors called a cardiac incident. He was in and out of the hospital four more times due to heart disease. By May, he needed a triple bypass.

Though we have excellent insurance benefits through my husband's company we still incurred a great many bills. There were bills from doctors I never heard of, bills for services I didn't understand, bills for items I couldn't identify. Some of these bills were pages and pages of numbers and words that made no sense to me. How was I going to figure out what was what, and more importantly, what I should and shouldn't be paying for?

I managed to sort through the piles of paper and determine what payments I was responsible for and which were covered by insurance. Everything was in order. I thought the billing nightmare was coming to an end. I was wrong.

The hospital at which my husband had his surgery sent a bill for $364.45. This bill came in January of 2006, eight months after he had been released. The amount was identified as Current Balance. No other explanation was given.

I called the number on the bill. I asked what the charge was for. The woman who answered could only tell me that the amount was the current balance left on the bill. Obviously, she was not going to be of any assistance.

After several phone calls, I ended up on a three-way conference call with the insurance company and the hospital. The hospital representative could not identify the charge, only that it was to be paid. The insurance company representative pointed out that it would not pay for an unidentified charge. The hospital representative pointed out that that was why it was billed to the patient, because the insurance company didn't pay it.

I stated that I was not going to pay for something without knowing what that service or item was. No resolution was reached. The hospital handed the bill over to a collection agency.

By this time I was ready to have a cardiac incident of my own.

Health Advocate to the rescue!

My husband came home from work one day and said he found out that part of the insurance coverage benefits was access to a health advocacy service. Not knowing what that was, I asked what it would cost us.

It would cost us nothing. We only had to make a phone call and explain the situation.

Could anything involving medical bills, health insurance, and hospitals be that simple? Based on my past experience, I had my doubts.

I handed over all the pertinent paperwork, including my notations of dates of phone calls and names of personnel written on the backs of billing envelopes, to my husband. I had had enough of this, and figured my husband was well enough to take a little added stress. I wasn't sure my own health would have stood another moment of this nightmare.

My husband made the call, and explained the situation to a PHA, a Personal Health Advocate, named Carl.

Within two weeks Carl called my husband and said the issue had been resolved. We did not need to pay the $364.45. Furthermore, we were entitled to a $40 refund.

I was stunned. I was grateful. I couldn't believe there was someone out there that could navigate the complex structure that is our health care system and resolve this issue to our favor. The nightmare was over.

But who are these health care advocates and how do they banish the nightmares?

From this quagmire that is now our health care system a new industry is emerging. It is the health advocacy industry and it is in answer to an ever-increasing number of consumer complaints and lawsuits.

Health Advocate is an industry leader. Established in 2001, the privately held company was founded by five former Aetna Healthcare executives.(1) The company contracts with organizations that provide group health plans to their employees. Their services are in advocacy to the members of the health plans, the employees. The Personal Health Advocates are trained professionals, backed up by staff drawn from the medical community, such as administrators and medical experts. They understand the inner workings of health care, billing, insurance, and other aspects of the system. When an employee contacts Health Advocate for assistance, he or she is assigned a Personal Health Advocate,(PHA) and that is his or her contact. That is the person the employee will speak with, each and every time.

It is the job of the PHA to assess the employee's situation, contact all necessary parties, and reach a resolution. All the hours I spent on the phone, all the fruitless conversations, all the stress I experienced, came from my lack of knowledge and contacts within the system. A Health Advocate PHA has the knowledge and contacts to avoid just such a situation.

As health care and health care coverage become more prominent issues in the news and in politics, it becomes obvious that the average consumer will need greater assistance during times of medical crisis. Sarah Lawrence College offers a masters degree program in health advocacy. The college defines the field this way:

"Health advocacy encompasses direct service to the individual or family as well as activities that promote health and access to health care in communities and the larger public. Advocates support and promote the rights of the patient in the health care arena, help build capacity to improve community health and enhance health policy initiatives focused on available, safe and quality care."(2)

Health advocates will be the people who stand between the consumer and the institutes. They will protect the patients' rights in every area, up to the legislative forums of Congress. They will be the interpreters of the medical language, the code breakers of billing, the investigators of erroneous charges. They will improve the level of care in communities and lobby Congress to improve the health care systems.

Most of us get our health care through our employers. I would encourage everyone to ask his or her employers if the health care plan offers an advocacy service. Such services offer not only assistance with billing, but with medical scheduling issues, help with getting second opinions and dealing with claims, and understanding complex medical diagnoses and terminology.

A medical crisis is a two-part nightmare. But now, at least, there is someone who can help, someone who can challenge the demons of the health care systems. Health advocacy is a field filled with promise. Advocates will be able to reduce the stress for patients and families, and will be essential in the restructuring of the health care system.

1)http://www.healthadvocate.com/companyprofile.asp

2) http://www.slc.edu/health-advocacy/Defining_the_Field.php