Does Insurance Cover That?

insuranceInevitably when I’m asked what I do and respond that I’m a private patient advocate, one eyebrow raises, followed by “What’s that?”

My “Private Patient Advocate” elevator speech goes something like this:

“Private patient advocates are independent professionals that help patients and their families clarify options for managing their healthcare as well as the cost of their care. This might mean things like sourcing a doctor for a second opinion, facilitating better coordinated care, researching nursing homes, or negotiating insurance claims and medical bills.”

Hint: The operative word in that elevator speech is “independent.”

The typical response is “Boy, we sure need people like you.” Followed by, “Does insurance cover that?”

The short answer is “No, it doesn’t.” And from my perspective I’m not sure I would want insurance to cover what independent private patient advocates do.

Our healthcare system is incredibly fragmented with multiple stakeholders in our care, all with personal as well as external drivers for the role they play. In truth, many of those people and organizations advocate for us as patients, including, but not limited to insurance companies (yes, insurance companies), doctors, nurses, pharmacists, hospitals, and social service agencies we engage with.

But they often aren’t connected, and the advocacy they provide for us is limited by their available time and to the specific issues for which we see them, not to mention by who pays them.

Insurance companies frequently provide nurse advocate services, but their primary focus is on those of us who are costing the healthcare system the most. They attempt to close what they refer to as “gaps in care,” clinical activities that we aren’t getting that keep us healthiest. They advocate for us to get those services because healthier, compliant patients cost the system less to manage. I’m a big proponent for evidence-based medicine, but insurance nurse advocates have their hands tied to advocate for us when we want or need something outside of those “gaps in care.”

Hospitals also often have patient advocates or ombudspersons available but their role is limited to the time you’re in the hospital, which these days is shorter and shorter. While they can help when you’re unhappy with your hospital-based care, even with the increasing focus on preventing hospital re-admissions, the resources that are put in place after leaving the hospital often fall short.

Increasingly I am seeing advocates embedded in physician practices. Their role is often focused on insurance approvals and treatment support within the practice, which is a very important part of our care. But they don’t help us as patients prepare for our encounters with our physicians so that we become more effective patients and get from the encounter what we want. And there may be broader issues outside the scope of that care that don’t make sense for them to facilitate when it doesn’t support the practice (like a second opinion, or understanding why not to consider a recommended treatment).

Some employers offer advocacy services as an employee benefit that support navigating issues related to costs of our care, including improved cost transparency and support to better understanding our insurance. But these services are limited to the employees of the employers who purchase them. If these aren’t a part of your benefits package, finding an impartial resource to help with the myriad of issues that come from navigating our insurance and medical bills can be daunting.

If we don’t have a family member, a friend, or an independent professional patient advocate to act as a “general contractor” for all the resources we do have, there isn’t a voice for us in the healthcare system that can cross the silos that fragment our care. After all, it’s our care, and keeping the focus on us rather than on the pieces and parts of the system is what a private patient advocate does.

I’m not aware of insurance coverage that provides for other independent professional assistance, like tax assistance or legal assistance. Private patient advocacy is essentially professional healthcare system assistance.

Are our services covered by insurance? No, but that may be the best thing about us.

To your health and wellbeing,

Cindi

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