Key Takeaways
- Most private health insurance plans don't directly cover patient advocacy services, but some exceptions exist through specialized benefits or care management programs.
- You can connect with a patient advocate covered by Medicare and other insurances by using Pinnie.
- You can also access advocacy help through hospital patient representatives, nonprofit organizations, and employer health benefits.
Patient advocates serve as personal guides in the healthcare system, helping patients understand their treatment options, reviewing medical bills, communicating effectively with healthcare providers, and ensuring proper care delivery.
Whether or not patient advocates are covered by insurance depends on your insurance carrier and plan. In this article, we explain what patient advocates are, which plans may cover patient advocacy, and who might benefit from accessing one.
You can also use Pinnie to access a patient advocate covered by health insurance.
What Are Patient Advocates?
Patient advocates are professionals who help people navigate the complex healthcare system. Think of them as your personal guide and supporter during medical care. They can help explain treatment options, review medical bills, communicate with healthcare providers, and ensure you receive appropriate care.
These advocates come in different forms: professional independent advocates hired directly by patients, hospital patient representatives employed by healthcare facilities, insurance company case managers provided by your insurer, and nonprofit organization advocates often focused on specific conditions.
Does Insurance Cover Patient Advocates?
Coverage varies widely depending on your insurance type and specific plan.
Private Insurance Coverage
Most private health insurance plans don't directly cover services from independent patient advocates. However, there are some important exceptions.
Some coverage possibilities include care management programs for complex conditions, employee assistance programs through workplace benefits, premium "concierge" health plans, and case management services for specific diagnoses.
Aetna's "Care Advocate" program and UnitedHealthcare's "Advocacy Services" are examples of insurer-provided advocacy services that come built into some plans at no additional cost.
Medicare Coverage
Traditional Medicare (Parts A and B) does not cover services focused only on patient advocacy.
However, Medicare does provide free access to State Health Insurance Assistance Program (SHIP) counselors who help with Medicare questions, Medicare beneficiary ombudsman services for complaints, and hospital patient representatives during hospital stays.
Some Medicare Advantage plans (Part C) offer additional care coordination benefits that function similarly to advocacy services.
These plans are offered by private insurers and may include care managers for complex conditions, nurse hotlines for medical questions, and social workers to help with care transitions.
Medicare covers Principal Illness Navigation services, which are designed to support beneficiaries with serious or complex medical conditions.
These services include elements of patient advocacy, such as care coordination, assistance in managing treatment plans, and communication with healthcare providers.
Beneficiaries who qualify for Principal Illness Navigation can access advocacy-related services tailored to their specific clinical needs, helping them navigate their healthcare journey more effectively.
Pinnie Advocates participate in Medicare-covered Principal Illness Navigation to effectively and efficiently deliver advocacy and illness navigation services.
Medicaid Coverage
Medicaid coverage varies by state, but most states offer some form of patient advocacy services through care coordination programs, case management for specific populations, ombudsman services for nursing home residents, and waiver programs for people with chronic conditions or disabilities.
When Might You Need a Patient Advocate?
Understanding when an advocate might help can clarify whether pursuing coverage is worthwhile:
Complex Medical Situations
If you're facing multiple chronic conditions requiring numerous specialists, a new serious diagnosis like cancer, rare diseases where treatment options are unclear, or an upcoming complex surgery or treatment regimen, an advocate can help coordinate care between providers and explain treatment options in clear terms.
Billing and Insurance Challenges
Patient advocates are particularly helpful when receiving surprise medical bills, fighting insurance claim denials, negotiating medical debt, or applying for financial assistance.
Communication Difficulties
Advocacy services prove valuable when doctors use confusing medical terminology, you need help preparing questions for appointments, family members need updates about a loved one's care, or language barriers exist between you and providers.
How to Access Patient Advocacy Services
If your insurance doesn't cover patient advocacy, consider these alternatives:
Hospital-Based Advocates
Most hospitals employ patient representatives or patient relations staff at no cost to patients.
These advocates can address concerns about care, facilitate communication with the healthcare team, help resolve problems during hospitalization, and connect patients with hospital resources.
While these advocates work for the hospital, they can still provide valuable assistance navigating care within that system.
Nonprofit Advocacy Organizations
Many condition-specific organizations offer free advocacy services:
- American Cancer Society's patient navigator program
- Alzheimer's Association care consultants
- Patient Advocate Foundation (for chronic/life-threatening illnesses)
- Local Area Agencies on Aging for older adults
These services are typically funded through donations and grants, making them accessible regardless of insurance coverage.
Employer-Provided Advocacy Benefits
A growing trend among large employers is offering health advocacy services as an employee benefit.
How to Check If Your Insurance Covers Patient Advocates
Follow these steps to determine potential coverage:
- Review your insurance documents. Look for terms like "care coordination," "case management," "patient navigation," or "health advocacy" in your benefits summary.
- Call your insurance company. Ask specifically about coverage for patient advocacy services, available case management programs, care coordination benefits, and health coaching or navigation services.
- Speak with your employer's benefits coordinator. They might know about advocacy services available through your workplace benefits package that aren't clearly listed in insurance documents.
- Check with your doctor's office. Some medical practices, especially those in patient-centered medical home models, offer care coordination services that function like advocacy.
Paying for Patient Advocates Out-of-Pocket
If you need to hire an independent advocate without insurance coverage, here's what to expect:
Typical Costs
Independent patient advocates typically charge hourly rates between $100-$350 per hour (national average: $175/hour), flat fees of $1,500-$5,000 for specific projects like resolving a billing dispute, or monthly retainers of $500-$3,000 for ongoing support.
Medical billing advocates often work on a contingency basis, taking a percentage (typically 25-35%) of the money they save you.
Finding Qualified Advocates
To find a reputable advocate ask for recommendations from healthcare providers, contact condition-specific nonprofits for referrals, or check for certifications like Board Certified Patient Advocate (BCPA). You can also find an advocate using Pinnie.
When interviewing potential advocates, ask about their experience with your specific healthcare needs, fee structure and payment expectations, communication style and availability, and professional background and credentials.
The Bottom Line
While direct insurance coverage for patient advocates remains limited, various pathways exist to access similar services.
Utilize free hospital patient representatives for facility-based concerns. Tap into condition-specific nonprofit resources.
Check employer benefits for included advocacy services. Consider the potential return on investment for paid advocacy when facing complex issues. Explore insurance plan features that may include elements of advocacy like care management and nurse hotlines.
Patient advocacy services provide valuable support that can improve outcomes, reduce stress, and potentially save money. Even without insurance coverage, the benefits often outweigh the costs for those facing significant healthcare challenges.
