A Guide Through a Medical Wilderness

A Guide Through a Medical Wilderness

A Guide Through a Medical Wilderness 150 150 Medical Cost Advocate


As the government churns through health care reform, the media has realized that consumers can negotiate their health care with doctors and hospitals.  The article indicates that it is best to choose an advocate with a successful track record in health care cost reduction.  Medical Cost Advocate is a leader in health care cost reduction through expert negotiation.




New York Times




THESE days, dealing with medical bills and insurance claims makes April 15 look easy. The medical jargon and inscrutable coding on invoices and explanations of benefits are indecipherable for most lay people. Worse, seriously ill patients may simply be too sick or too broke to deal with the mountains of red tape. That can lead to unpaid medical debts and even bankruptcy.


It’s no wonder that a cottage industry has sprung up to fill this void. Known as medical billing advocates, these middlemen and women help patients deal with the paperwork and haggling often associated with medical costs.



In general, medical billing advocates help you find errors in your bills, negotiate with your insurer to appeal coverage denials, or negotiate lower fees with your medical care providers. Some advocates do all three tasks equally well. But others, because of their training or background, may specialize in one area or another.


Still others give the client the ammunition he or she needs to negotiate. That’s what happened to Susan Redstone, a freelance fashion stylist and author. When she broke her back in a horseback riding accident last summer, she held only a bare-bones insurance policy. So Ms. Redstone, who has since recovered, knew that she would be responsible for the bulk of her medical expenses.



Five months after the accident, just when she thought she had paid everything off, she got a bill for $16,000 from the helicopter ambulance service that ferried her from the remote location in Colorado where the accident occurred to a large medical facility 75 miles away. “I was completely taken by surprise to get this bill so long after the accident happened,” Ms. Redstone said. She consulted with Victoria Caras, a medical advocate in Aspen, Colo., who coached her on how best to approach the medical transportation company to lower her bill. With Ms. Caras’s advice, Ms. Redstone was able to negotiate a 25 percent discount in exchange for paying the bill in full.


Medical advocates are costly, often charging 30 percent of whatever costs they recover or an hourly fee of $100 or more, depending on the type of work they are doing for you. (The initial consultation with a medical advocate should be free. After that, fees should be spelled out in a formal contract.)


The high charges can certainly be worth the expertise an advocate can bring to a medical billing quagmire. But because the profession is so new, there are no degree or certification programs in place. “Anyone can hang out a shingle in this business,” says Kevin Flynn, a health care advocate in Philadelphia who is working with the University of Miami to start an online education and certification program. Thus, he adds, it’s important to choose your advocate as carefully as you choose your doctor.


The Medical Billing Advocates of America does list advocates in various states and by specialties on its Web site, but an advocate is listed only if he or she has completed — and paid for — courses sponsored by the organization.


For now, recommendations from family, friends and, in some cases, your doctor or other health care provider are the best way to get started. Most important, says Mr. Flynn, is to find an advocate with a strong background in the type of problem you’re facing. Here are some things to keep in mind when looking for a medical advocate:


According to some surveys, as many as 9 out of 10 bills from hospitals and medical providers include errors, according to the Medical Billing Advocates of America. Often these errors have to do with billing for services that were not provided. Lin Osborn, a medical advocate in Westchester County, N.Y., says she has seen several cases in which patients were charged a separate fee for closing a surgical incision. That practice, says Ms. Osborn, is a clear violation of government Medicaid and Medicare guidelines; it should be included in the fee for surgery.


Or, Ms. Osborne adds, someone may be charged for an expensive “level 4” pathology report when they received a less comprehensive and less costly “level 2” report. “This kind of thing happens all the time,” said Ms. Osborne. “But if you don’t know how to read the codes and ask the right questions, you might never know you’re paying too much.”


Then there are the well-publicized overcharges like $11 for a box of tissues, itemized as “a disposable mucus recovery system” or a $15 bag of ice listed as “thermal therapy.”


Medical advocates can wade through these charges, point out the absurdities and negotiate more realistic rates. Finding billing overcharges and errors like these can be especially helpful for uninsured or underinsured patients who are paying these expenses out of pocket.


If you think you’re being overcharged, look for an advocate who has worked previously in a hospital or medical provider’s billing office. He or she will be familiar with some of these tricks and will also understand the hieroglyphics on your bills and explanations of benefits.


Ask the advocate you are considering if he or she is familiar with diagnostic codes. Many professionals supplement their previous knowledge with courses specifically designed to learn the medical coding process. They may even earn a designation as a certified professional coder, or C.P.C.



If your claims have been denied for whatever reason, you have the right to appeal that decision. But you’ll soon learn that the appeals process is complicated, frustrating and time-consuming, especially if you’re trying to fight while you’re sick. “An outsider can take the emotion out of the argument and speak the insurer’s language. We’re not intimidated,” says Ms. Caras, the Colorado advocate.


Judy Medeiros, a health care advocate in Stanfordville, N.Y., recently talked with a client who had knee-replacement surgery. During his recovery, he started receiving bills from physicians other than the surgeon who treated him during his hospital stay. Coverage for those fees was denied because the insurer claimed these doctors were not part of the patient’s network.

In cases like this, Ms. Medeiros and other advocates handle the appeal and negotiate with the insurance company to get the fees covered, hopefully in full, or at least partly under the insurer’s out-of-network coverage.


If you need help handling a dispute with your insurance company, advocates who have a background in insurance claims departments or lawyers with a strong health care background often have the skills you’re looking for. Be sure to ask for several references of previous clients with cases where the advocate has successfully negotiated with an insurance company.



Unfortunately, appeals may be denied and the patient may remain responsible for the bill. Or, a patient may already realize that his or her insurance policy, or the lack thereof, won’t cover certain medical expenses. In these cases, a medical advocate can often help reduce your out-of-pocket costs by negotiating lower rates directly with your medical care provider.


Doctors and other providers often accept much less in fees from insurance companies than they charge individuals. Advocates try to get providers to charge individuals the same rate they would charge someone with group coverage, and in many cases they will also negotiate a payment plan over several months on a client’s behalf.


Again, an advocate with a strong health care background and a long history of successful negotiations is your best bet in these situations