woman examining insurance reimbursements

Insurance Reimbursements for Patient Advocates?

This is one of those questions I’m asked frequently. It recently popped up again:

When will private patient advocates be reimbursed by insurance?

In fairness, the question is usually asked by those who either aren’t advocates, or are in the very early stages of thinking about patient advocacy as a way to make a living. They haven’t been exposed to the issues involved on a regular basis, so the obvious answers aren’t so readily apparent.

But whether you’re a total newbie, or you’ve been dancing in advocacy circles for awhile, there are two answers, at least for now:

> probably never

> hopefully never

If those answers surprise you, then you don’t know enough about health insurance and/or you don’t understand one of the most important attributes of private, independent advocacy.

Health insurer reimbursement for private, independent advocates would not only create a conflict of interest, but would drive most advocates out of business. In any case, reimbursed advocates would no longer be private NOR independent.

Let’s break it down. Among the most important attributes of private, independent, professional patient advocates is that they are… independent.

Independent of what? Independent of the payment system which has created most of the hurdles patients encounter with the system, for which they seek solutions. Being outside the payment system is precisely what creates the advocate’s objectivity. When it comes to guiding patients and supporting patients’ decision-making, advocates don’t profit based on the choice the patient makes. Their only goal is to achieve the best outcome for their client, without regard to how much money any provider or facility will profit from, or save. Their allegiance is solely to their clients; they are beholden to no one else. That’s the major reason they can be so effective.

paperworkBut health insurers are quite the opposite. Within the system, health insurers control the flow of time, information, and payment, because their primary goal is to save money and increase profits. Health insurers actually go to great expense to limit their expense. Here are a few examples:

  • Insurance won’t pay for time doctors spend with their patients, which means patients don’t get the information they need to choose the best way forward for themselves.
  • Insurance refuses some treatments (rationing) because they deem those treatments to be too expensive (too expensive for what?); a drain on their profits.
  • Insurance pays only for portions of some treatments (ex: they’ll pay the surgeon, but not the anesthesiologist) to limit their expense.
  • Insurance negotiates ridiculously low reimbursements knowing providers or hospitals have little choice but to agree to them. In return, providers and facilities then limit what they’ll provide to their patients.

So….. it would follow logically that if insurers reimbursed advocates, they would pay advocates only for some things done on behalf of patients, and not others – identically to how they pay medical providers. They would ration the time and activities an advocate could be paid for – identically to how they pay medical providers.

Once an advocate’s work and pay are rationed, then he or she is no longer working strictly in the best interest of the client. Her allegiance is now elsewhere – with the insurer and not the client. That probably would not be by choice. But it would definitely be by necessity, just to keep one’s practice afloat.

Further, advocates would be forced to adhere to the rules put forth by the insurer, as follows: You, Mr. Advocate, may be reimbursed for this and this, but not for this. We will allot you only X amount of time for this patient, so if you run over, you won’t get paid. Yes, we know you charge $200/hour, but we’ll reimburse you only $50 an hour, and it will take an hour’s worth of paperwork to submit for the reimbursement – plus – we won’t pay you for 90 days.

(In other words, you work one hour for the patient, plus one hour of paperwork = $50 for two hours of work. You submit the paperwork in February for the work you did in January and you get paid in May.)

So, back to my original statement…. in answer to the question, “When will patient advocates be reimbursed by health insurers?”

Probably never: because health insurance companies would see advocates as an extra expense, and of course, they aren’t interested in spending a single penny more than they have to.

Hopefully never: because the minute an advocate would accept a reimbursement from an insurer, it would make it almost impossible to avoid conflict of interest in her work with her client. Further, it would make it extremely difficult to stay in business.

So how do we translate this to potential clients who ask whether their insurance will pay for our services?

It’s actually quite simple. The answer is “No, and you don’t want insurance to pay for my services. Here’s why.” … whereupon you provide them with the explanations above. They’ll get it – because it’s like a light bulb of understanding. They will better realize why they aren’t getting what they need from the existing system, and they’ll further understand that it’s your independence that means you can work around the system to help them get what they need and improve their chances for their best outcomes.

And that’s what helps us, as non-reimbursed, objective, capable, INDEPENDENT patient advocates, sleep well at night.

Just say NO! to insurance reimbursement for patient advocates.

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Agree? Disagree?

Share your experience or join the conversation!


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