More People Turning to Patient Advocates to Resolve Disputes with Health Plans and Doctors

The New York Times on Jan. 6 profiled independent personal advocates, professionals hired by patients to help them resolve disputes with health insurers and doctors "over what treatments are medically necessary and who should pay for them." As the number of people "finding themselves personally haggling" over medical coverage has risen in recent years -- the New York State Insurance Department alone received 22,000 complaints over denials of health care claims in 1999 -- patient advocate services have "sprung up," many started by people who have "had their own share of problems with managed health care." Advocates either work directly for patients for a set fee or a percentage of the reimbursement, or they work for employers and charge a "small monthly fee," usually less than $1 per month per employee. The Times reports that the advocates are "not to be confused with lawyers who specialize in health care cases or the patient advocates hired by hospitals." Companies offering independent patient advocate services include Healthcare Advocates of Philadelphia, Managed Care Resolutions of Seattle and Care Counsel of San Rafael, Calif. Wolfgang Klamp, a health care management consultant, said, "People really need the help. People go bankrupt for this. They don't know where to turn."

Other Options
The Times reports that not everyone needs to turn to patient advocates, as there are "plenty of free services" to assist health care consumers with complaints. Many employers' human resources departments or benefits managers can help employees deal with insurers. In addition, all managed care companies have an appeals procedure with an "in-house reviewer, usually a doctor," and in most states, patients can appeal to an external review board. Patients also can appeal to state agencies that regulate health care insurance or to Medicare or Medicaid agencies that exist in every state. Consumers who still want additional help can research patient advocates via the Internet. The Times reports that many patient advocates will not accept a case unless they believe there is a "strong chance of having their [client's] medical needs met." In most "uncomplicated cases," an advocate will "explai[n] the system" and then let patients or family members "become their own advocates," Dr. Vincent Riccardi, an independent patient advocate and internist, said. Making a health plan change its decision sometimes merely requires patients "contact[ing] their doctor to make sure that he or she uses the correct language in a health plan contract," Riccardi added (Freudenheim, New York Times, 1/6).