How A Private Patient Advocate Can Help When A Loved One Is In The Hospital
I often am asked the question, “how can a private patient advocate help while someone is in the hospital?” The healthcare team at the hospital includes so many people already, for example doctors, physician assistants, nurses, case managers, social workers, therapists, aids, resident doctors, students, and often even hospital-provided patient advocates. With all these people involved in a patient's care, what additional assistance can a private patient advocate offer?
This is a great question. To help explain, I would like to share a recent patient story. (real name changed for privacy purposes)
A Patient Story…
June Smith had already been in the hospital for 41 days when I was hired as her private patient advocate by her husband. The initial request from the husband was to assist with finding the best options for an outpatient rehabilitation facility and help assist with the transition of care. As I began discussing discharge options with the case manager, she informed me that the patient’s top choice for a rehabilitation facility had been denied due to a specific clause in her insurance, and therefore, no rehabilitation would be covered. The case manager explained that due to the insurance clause, June would not qualify for discharge to any rehabilitation facility, and her lengthy hospital stay would also not be covered by insurance.
As I began discussing discharge options with the case manager, she informed me that the patient’s top choice for a rehabilitation facility had been denied due to a specific clause in her insurance, and therefore, no rehabilitation would be covered.
The following day June's doctors and the rest of her healthcare team, read the update in June’s chart about her lack of insurance coverage and continued to replicate documentation of this in her chart.
This unexpected news left June and her husband very frazzled and worried about how they were going to cover these costs and where June would be discharged to. It was not yet safe for June to return home after being discharged, as she required much more therapy.
The information shared about June’s insurance clause did not seem very clear to me. I contacted June’s insurance company to further discuss the details of the clause. During the call, the insurance company clarified to me that the clause was only valid under a very specific medical situation, one that did not apply to June. The insurance company confirmed that her policy would cover rehab services, as well as her current inpatient hospital stay at 100%.
The hospital misinterpreted coverage under their insurance policy. They were so relieved that I was able to help save them several hundred thousand dollars, by identifying and correcting this mistake
After sharing the insurance policy details with the hospital, it was determined that the hospital has misinterpreted June’s coverage under her insurance policy. June and her husband were so relieved that I was able to help save them several hundred thousand dollars, by identifying and correcting this mistake. As a result, June was able to be discharged to the facility of her choice and received the proper rehab needed to get her back safely on her feet.
What’s the Difference Between a Private Patient Advocate and an Advocate Provided by your Hospital or Healthcare Insurance?
While they are often confused as the same position, there is in fact a BIG difference! Many hospitals do now offer a patient advocate, however they practice more like customer service representatives. The patient advocate may refer you to the billing department or other areas in the hospital. While their services may at times be useful, they typically do not themselves have a medical or billing background. More importantly, they are employed for the healthcare system or insurance company, therefore your (the patient/family’s interest) is not the first priority.
A private patient advocate is an unbiased individual, who focuses on YOU. A patient advocate helps navigate your path to the best possible care for YOU.
This story is just one of many examples of how a private patient advocate can help. When a loved one is in the hospital, it is a very emotionally overwhelming experience. A private patient advocate can help in various aspects during the stay; from reviewing records, insurance and billing issues, communicating with the healthcare team, coordinating care, and helping reduce medical errors.
If you have a loved one in the hospital, call Pathway Patient Advocates (947) 517-8395 to discuss how a private Board Certified Patient Advocate can help you.
For a self advocacy perspective, check out this blog: Regaining Your Strength After a Hospital Stay: 5 Tips!
For another patient advocate perspective, check out this blog: Don't Be a Complacent Patient