Question: What if I have attempted and failed to resolve issues? How is a advocate effective?

Answer: Health Advocates knows the industry, patient rights, and rules to cut through the red tape. Our expertise and experience helps us find great solutions to complex billing and claim issues. Health Advocates are now well known by the insurance companies and health care providers. They will not back down, we know how and we usually get you great results. Hospital and insurance companies usually want to resolve matters once a health advocate is on the case.

Quesiton: Who needs a Health Advocate?

Answer: The health plan or insurance companies generally have their own criteria in choosing clients that may benefit from Case Managers or Health Advocate, however you may request a Case Manager or Health Advocate any time when you feel that you can benefit from their services. Some examples of scenarios that may require a Case Manager or Health Advocate:

  • You have a child with multiple health problems and requires a lot of health care services.
  • You or your child has a serious health issue. For example, a premature baby with congenital heart disease or a child with serious cancer diagnosis.
  • You have a chronic illness such as diabetes, asthma, cancer, heart disease and you require assistance with coordinating health care services.
  • Catastrophic illness or injury that requires complex health care planning. For example, people who have had a heart attack, stroke, or spinal cord injury.
  • You are pregnant and have a high risk for complications. You may need close monitoring by home health provider that specializes in maternity care.
  • You have a serious health issues that may require referrals to center of excellence. For example, people with End Stage Renal Disease  requiring transplant services.

Question: What is a Health Advocate? Answer: Health advocate is a designated clinical consultant who organizes a wide variety of health care-related support and educational services to maintain, improve, and manage health of a patient or client. Advocate will assist client/patient navigate the healthcare system to address any health care needs. Socal advocates have years of experience dealing with patient/client health issues including coordinating services with  doctors/specialists, hospitals, insurance companies, ancillary providers, and other health clinicians. Advocate can help patient/client with learning about their health benefits, programs, and resources. Advocate can prevent illness or adverse outcome for a patient/client by identifying health risks early. Experienced medical health advocates can effectively help a client manage his/her healthcare by removing obstacles, providing timely access to care, delivering personalized care and promoting safe/quality outcomes. Health advocate role can combines an administrative and clinical approach.

  • Navigator
    • Help locate the quality doctor or facility to meet patient/client’s needs.
    • Arrange medical services.
    • Review health plan benefits with patient/client; including plan type, review of deductible, Out of Pocket cost, and lifetime maximum.
    • Educate patient/client on Network vs Out of Network benefits, covered, and non covered services.
    • Schedule appointments with doctors/specialist or ancillary providers
    • Provide tools that can help patient/client receive patient-centered or personalized care.
    • Work with patient/client insurance on claim issue if identified.
    • Help patient/client appeal an adverse outcome/denied services.
    • Help patient/client negotiate charges on claims that may be out of network.
    • Provide unbiased research on condition or diagnosis.
    • Identify and facilitate resources to maximize benefits for patient.
    • Assist patient/client with prescription drugs issues (insurance, polypharmacy, side-effect management)
    • Assist patient/client with appropriate referrals to get the patient/client the help they need.
    • Provide/facilitate timely referrals to  available community or/and employer resources.
    • Educate/Provide access to routine preventive services recommended by U.S. Preventive Service Task Force (USPSTF)
  • Manage Acute, chronic, co-morbid diagnosis/conditions
    • Collaborate with the doctor or specialist to coordinate all needed services.
    • Prepare patient/client for an inpatient hospitalization admission for medical or surgical needs.
    • Provide education regarding a procedure, surgery, or disease process.
    • Helping patient/client understand tests, treatments, and medications recommended by their doctor or specialist.
    • Facilitating second opinion with another physician/specialist for confirmation of diagnosis and treatment.
    • Identify and facilitate resources needed pre or post discharged from the hospital.
    • Assist with transition to lower or higher level of services.
    • Research/Identify Centers of Excellence of condition/disease management for second opinion or treatment.
    • Appeal adverse decision or determinations by insurance or insurance administrators.
    • Collaborate with patient/client and their family to assist with anticipated healthcare needs.
    • Identify psycho/socials issues interfering with patient/client’s return to optimal health.
    • Identify available specialized benefits or health programs to manage health issues.

Q: Why should I use Health Advocate and not a lawyer? Answer: “I was referred to you by my lawyer”, one client said. Lawyer don’t usually work on these types of issues and may not have sufficient experience to answer your questions.

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