Healthcare Problem or Medical Crisis?

Patients and their loved ones are always at a disadvantage when it comes to making decisions about medical care. A complicated diagnosis, unexpected decline in health, or traumatic injury can make it nearly impossible for patients and families to advocate for themselves. There are barriers and obstacles around every corner. Sometimes it’s hard getting answers to the most basic questions.

Advocating for yourself as a patient is often problematic for several reasons. First, our healthcare system is complex and intimidating. It can be extremely challenging for patients and their loved ones to make informed decisions, especially during periods of uncertainty like when it’s time to be discharged or when it’s unclear whether a test or procedure will be approved.

Furthermore, patients don’t always have access to everything they need in order to make informed decisions, such as their complete medical records, information about treatment options, and the availability of clinical trials.

These factors can make it extremely difficult for patients and their families to effectively advocate for themselves. The right Independent Patient Advocate, however, can step in, take charge, and help patients and loved ones speak up when friends and family just aren’t enough.

Everyone employed by a health care company is limited to what they can accomplish for patients and families. Hospital-employed patient advocates, navigators, social workers, and discharge planners are no different. They have heavy caseloads and work long hours with limited resources. Independent Patient Advocates, however, work one on one with patients and loved ones to explore options, improve communication, and coordinate with overworked hospital staff. In fact, many Independent Patient Advocates used to work for hospitals and healthcare companies before they decided to work directly for patients.

Hospital-employed patient advocates are also beholden to hospital policies and procedures. Because they are accountable to hospital administration, they can be restricted in their ability to advocate beyond rigid corporate guidelines. Independent Patient Advocates, on the other hand, can be more objective because they are not associated with a specific healthcare provider and are not financially dependent on any one organization. They can often provide a wider range of services and have more freedom to advocate for patients and their loved ones.

The education and training of Independent Patient Advocates can vary widely. Some Independent Patient Advocates have backgrounds in healthcare, such as nursing, social work, aging life care, or healthcare administration. Others have experience in insurance, rare disease, long term care, pharmacy, or as caregivers for loved ones. A growing number of Independent Patient Advocates are former patients and survivors who have mentored others who are experiencing injuries and illnesses similar to theirs.

The Patient Advocate Certification Board (PACB) is the credentialing body for the profession. Independent Patient Advocates who have been certified by the PACB proudly display the BCPA credentials on their profile page. The Board works to manage and maintain a universally recognized certification for patient/health advocates; establish and maintain relevant knowledge domains, skills, ethical standards and best practices for advocates; collaborate with healthcare consumers to achieve patient and family centered care; establish professional development for certified advocates; and promote and professionalize patient advocacy.

Board Certified Patient Advocates are required to receive ongoing training and continuing education and most Independent Patient and Health Care Advocates routinely attend workshops, conferences, and other professional development opportunities to stay up to date with healthcare and patient advocacy.

Independent Patient Advocates are not yet covered by health insurance. They are hired directly by patients and their loved ones to provide individualized guidance and support that the traditional healthcare system is not equipped to handle.

The private-pay arrangement ensures that advocates remain independent and free from the influence of insurance companies and hospital facilities, whose interests are often not aligned with the patient's. Many advocates offer free consultations, sliding scale payment arrangements, and pro bono services, but most cannot sustain their businesses without charging fees.

Some health insurance plans provide limited coverage for non-medical services, such as case management or care coordination, and some offer coverage and make exceptions for Independent Patient Advocates in specific situations, such as for patients with complex medical conditions.

Employers have started offering patient advocacy services to their employees, and some labor unions and churches are also providing this support. As of January 2024, Medicare and Medicaid have started to pay for Independent Patient Advocacy services in certain situations. Please inquire if any of these options are available for you.

Independent Patient Advocates are not covered by health insurance for a couple notable reasons. First, health insurance companies are unwilling to pay Independent Patient Advocates to fight against their own policies and decisions. It is simply not in the best interests of health insurance companies to pay for Independent Patient Advocates.

In addition, many health insurance companies are reluctant to include Independent Patient Advocacy as a medically necessary covered service. Some health insurance plans do provide limited coverage for non-medical services, such as case management or care coordination, and some health insurance plans may offer coverage and make exceptions for Independent Patient Advocates in specific situations, such as for patients with complex medical conditions.

Employee benefit plans and employee assistance programs may cover Independent Patient Advocacy, but coverage varies depending on the specific plan and the insurance provider. Some employee benefit plans may offer coverage for Independent Patient Advocacy services as part of their case management or care coordination services. However, coverage depends on the specific terms of the employee benefit plan.

If you are considering using the services of an Independent Patient Advocate and would like to see if your employee benefit plan covers these services, it's a good idea to check with your insurance provider or HR department for more information. They can provide you with a summary of your coverage and any specific limitations or restrictions that may apply.