Patient Advocate--A Necessity in Navigating Healthcare

The healthcare field is changing rapidly, and it is not for the better if you are the patient. We see many excellent physicians leaving the field because of the bureaucracy and pressure, forcing us to find new providers. Doctors no longer work for themselves; they work for health insurance companies and are told how many patients they need to see per hour/ day, etc., and it is not enough time, especially as they often have to deal with medication denials, finding alternative treatments, and spending time on the phone on "peer to peer" reviews. These are when your health provider (often after the second or third denial) has to schedule a time with a representative from your insurance company who explains why they are refusing to cover testing or medications.

I don't know a single person who has not had to deal with denials, delays, underpayments, etc. My husband had prostate cancer, and although the abnormality was seen on an MRI, our insurance at that time did not allow for an MRI-guided biopsy (now the standard of care) and would only approve a "blind biopsy," where the doctor took a sample of the 12 most common sites where cancers are. I fought it, and it was approved. The doctor told us that if a blind biopsy had been done, the cancer would not have been found. However, it took a long time for the doctor's office to get paid, leaving a red "balance due" in his chart. When my husband called to make a follow-up appointment after telling the office staff that he was diagnosed with cancer, they refused to make it since he "owed money." That is where an advocate can come in. Some patients would hang up, embarrassed, and not have a follow-up. I called and got it resolved. He was able to see the doctor and continue his follow up care. But how many people have the tenacity and stubbornness to do this? A good Patient Advocate will do it and more.

As patients, we must be more proactive and prepared for our visits and potential denials and not count on our healthcare provider to do it all. I always ask my clients what their goals are with each doctor visit.

I recently went to an urgent care center for a bad cough, and, as has happened in the past, I realized that I would most likely need a steroid inhaler. Before I went in to be seen, I went online and saw which (if any) were covered by my Medicare drug plan. The answer, essentially, is that they are all only covered, but often only as tier 3 or 4, which potentially means hundreds of dollars. My next step was to check out the medications available through Good Rx and find out where they were less costly. Fortunately, having a medical background made it easier for me; when the PA told me I needed an inhaler, I gave her the list and fax number of the least expensive drugstores. She was incredibly grateful (and a little surprised). This saved us and her office and pharmacy time, which equals money.

Not everyone can do what I did, and working with an advocate (particularly one who is medically trained) is a major asset. Advocates can also review medications and make a comprehensive list of who prescribes them, why, and when to take them. Do you have any idea how many seniors are taking too many medications because healthcare providers don't always communicate with each other or your medication list isn't complete in your portal? A Patient Advocate can also research and provide a comprehensive medical history for all new medical providers. You will be amazed at how many things we, as patients, forget! While our medical records may be sent to new providers, they are often copious and poorly reviewed. When an advocate organizes a complete medical history, it can be given to all new providers, an ER doc, or the EMT who comes to your home.

As a Patient Advocate, I aim to help you with your medical journey before a significant illness or through a medical crisis. Most importantly, I will teach you how to become your own advocate, organize your records, and ask your provider questions to maximize your visits.

A trained advocate can also be used to start "The Conversation" about your final wishes, a conversation so many of us avoid. They can also help you understand Advance Directives and a MOLST/POLST form.

Don't be in the dark, and don't blame the insurance companies. It is a waste of time. They are oftenwrong, but educate yourselves to work with them and protect yourselves and your loved ones. Control what you can control, and let an experienced Patient Advocate help you when you need it.

Myra Katz