Advocates for hire: Getting paid for helping patients fight insurers

Two-thirds of doctors are already coping with insurers on behalf of patients to resolve claim disputes, a study says. Now a small number are doing this and more as part of a growing niche of health care advocate companies.

By Myrle Croasdale, amednews staff. June 3, 2002.

A handful of doctors are doing, for a fee, what many practicing physicians don't have time for -- guiding consumers through the U.S. health care system.

Products range from an Internet site for appealing denied claims to one-on-one help for any number of tasks, such as finding an affordable nursing home for an aging parent. Fees run the gamut of monthly memberships to flat rates per service.

Doctors as advocates for patients

Many physicians are already involved in helping patients cope with the demands of their health plans. According to a 1999 Kaiser Family Foundation and Harvard University School of Public Health Survey of Physicians and Nurses, 66% of respondents had contacted a health plan on behalf of patients outside of routine requests for referrals.

Making money at this rubs some the wrong way. Part of being a doctor is being an advocate for patients, they say.

Some doctors charge an extra fee for helping patients deal with insurers.

"I've spoken to physicians who've become defensive about this, saying, 'That's what I do,' " says Stanley Stier, MD, a medical management specialist and board chair for Patient Care, a fee-based patient advocate product of New Orleans-based Labyrinth HealthCare Group. "We see it as something to supplement what doctors do. We deal with the mundane, the unexplained bill. Members can call us anytime issues come up."

William Rees, MD, a pediatrician in private practice and an adviser for Healthcare Advocates Inc., located in Philadelphia, says doctors with a busy practice aren't able to fill the demands of an advocate.

"It takes a lot of time and concerted effort to get results," Dr. Rees says. "Writing letters goes nowhere. You have to be on top of it, and most doctors don't have the time. It's very difficult for doctors with their own practice to do this."

Negotiating the network

One of the most common consumer complaints these groups see is patients who have gone out of their plan's network or didn't have insurance when they became ill. Faced with big bills, they're looking for a way to cope.

Vincent Riccardi, MD, a medical geneticist and founder of American Medical Consumers Inc., based in La Crescenta, Calif., sees a lot of this. He's been working as a health care advocate for 10 years.

He came up with the idea for the business when he was working on his masters of business administration degree.

Besides the consumer medical consulting he does, he also works as a credentialing consultant for a health plan.

"The problem with medical advocacy is that many people don't understand what its value is," Dr. Riccardi says. "By the time we convince the patients or the caregivers of the value, we've given away the store. The cash flow for those of us in this business is very low. On the other hand, as we go toward medical savings accounts and high deductible insurance, this kind of service will be more valuable."

In dealing with people overwhelmed by steep medical bills, Dr. Riccardi says it's generally a matter of encouraging them to be proactive.

"You find the vast majority simply want the advice and the temerity to act on their own," Dr. Riccardi says. "You don't want a whole bunch of people involved in your health care. You want a sense you're on the right track."

The first step Dr. Riccardi takes with his clients is to find out what's going on and what kind of help they need. He charges $50 for a needs assessment, $50 to identify which resources would help them and $200 to review medical records. Charges for more complicated matters are worked out with the client.

"I'm not going to get rich. It's just a matter of accounting for your time," he says. "A significant portion of people call because they have a loved one who passed away, and they want their medical records reviewed. Most of the time the patient got great care and there's no reason to pursue a lawsuit."

Dr. Riccardi sees the demand for advocacy growing as baby boomers age.

"One of the largest patient populations in the country is Medicare. One of the problems is that they are so deferential to their physicians that they don't challenge them," he says. "That's part of the culture in which they matured. What we're going to be seeing very soon with the boomers is an unwillingness to be so deferential. When they become Medicare patients, there will be a lot more confrontation. My expectation is that the need for advocates, people to be able to guide them in a nonlitigious manner, will increase tremendously."

Taking the business to businesses

Patient Care takes a slightly different approach to patient advocacy. The company markets its services to employers, though it also offers individual memberships.

Jane Cooper, president and CEO, says the company has 15 employers with 2,500 employees signed on since Patient Care went live earlier this year. The company has a staff of five. While its marketing is focused on employers in the Louisiana region, its aim is to build a national clientele.

"We sell advocacy through employers for employees and their families," Cooper says. "We deal with claims issues, access to care, problems with referrals and authorizations, all the stuff that frustrates people."

In one situation, Patient Care helped a man who was living in a nursing home and had signed up with an HMO to save money. He wasn't aware his primary care doctor was not in the network. Patient Care found a network physician for him and arranged transportation to get him to his appointments.

In another instance, a doctor kept billing a member because the insurer wasn't paying. The solution ended up being getting the right claim form to the doctor's office.

Dr. Stier, who acts as Patient Care's medical director, acknowledges that advocacy is a difficult niche to fill.

"This is not a big moneymaker, but we think it's a big service-maker. Between what physicians require and insurers require, it's very confusing to most patients," he says. "There is definitely a role for someone advocating for the patient. Patients are furious and very upset at the moment they call. We try to bring them back to the level of resolving the situation without a lawsuit."

Patient Care charges employers $1.50 to $5 a month per employee. Its extended family program costs $10 per month for the first person and $5 a month for each additional person. Individuals can become a member for $15 a month or $25 a month for couples.

Dr. Rees, who practices outside of Washington, D.C., is another doctor sold on the idea of professional patient advocates. He read a newspaper article about Healthcare Advocates and its founder and president, Kevin Flynn; contacted the company and recently joined its advisory board.

Healthcare Advocates is supported by a panel of physicians, nurses, lawyers and individuals with experience in managed care. Its services include filing claims, appealing denied claims, appealing denied medical procedures and negotiating fees with hospitals and doctors. It will also track down medical research on individual diseases and find out which doctors specialize in its treatment. It's been up and running since 1996 and has a staff of 14.

Dr. Rees approves of the direction Healthcare Advocates is heading. Besides being able to concentrate its energy on tackling sticky administrative problems doctors don't have time for, he sees its team of experts as an asset in troubleshooting.

"Philosophically, I like what's Kevin [Flynn] is doing," he says. "There are a lot of people with problems with managed care companies and a lot of times we can help resolve them. I'd certainly refer patients to Kevin. He's gotten results. This is an old problem that's finally getting an answer."

ADDITIONAL INFORMATION:

Doctors as advocates for patients

How often have you or someone in your office made contact with a health plan on behalf of patients for something other than a routine request for a referral approval?

Often - 32%
Sometimes - 34%
Rarely - 13%
Never - 19%

Note: Percentages do not equal 100% due to rounding. Source: Kaiser Family Foundation and Harvard University School of Public Health, Survey of Physicians and Nurses, July 1999: a national random sample of 1,053 physicians and 768 nurses, asked only about their experiences with patients under 65 years of age