What can a healthcare advocate do that I can't?

A new diagnosis in the family is challenging to come to terms with, whether it is autism or other developmental disability or mental health need.  It is natural to want to rely on your providers for information about your family's entitlement to health benefits.  The challenge is that entitlement to your benefits does not belong in the hands of the provider; it belongs with you!  To obtain your entitlements, you must assert your rights with your insurer and/or your employer.  A professional healthcare advocate will assist you by

• decoding your plan (starting with whether it is regulated by the State, by ERISA or elsewhere)
•  knowing when, how and where to challenge the determinations that the insurance companies have made that are "adverse" ie against you
• knowing who is really on your side, and what to ask them!
• packaging and submitting your data in the most effective way 
• overcoming the inevitable barriers which emerge, like "lost" or delayed or incorrectly processed claims
• demonstrating a special understanding of the mental and behavioral health field where networks are slim and routes to reimbursement seemingly have roadblocks at every turn.    

A strong advocate will partner with you effectively to leave you with a greater awareness then when you started the process.  That way, you will enforce those rights yourself in the future.  

At intake you are asked to give the information that is needed to advocate on your behalf, including full plan documentation,  an authorized representative form (it is helpful if you ask your Insurer for their preferred form in advance), terms of engagement/remuneration, and contact information for you and your providers.   If the plan is self-funded, we also need contact information for the Employer's HR department.    Sara will sometimes ask to speak to the primary Insured in order to reiterate the importance of these steps.   Telephone contact with insurance company call centers is often the most time consuming part of the case.    Some consumers prefer to track the processing of individual claims and use the advocate's time to consult on the strategy, questions, communication and drafting.  

Sara is licensed as an Insurance Consultant (Life, Accident and Health) in the State of New York. She can also offer general healthcare advocacy advice and drafting assistance by telephone, video conferencing and correspondence nationwide.    Providers or non-profits should follow the Providers tab above, to access information about trainings.  

This is not legal advice.  Healthcare advocacy is designed to assert a person's healthcare and benefits rights within the appeals and grievance frameworks prescribed by the Affordable Care Act and ERISA and overseen by the State insurance departments  (in New York the Department of Financial Services) and the Department of Labor (self-insured plans).  The advocate is remunerated by the insured party, without expectation of an award of costs if the "claim" is finally paid.    Although there is no guaranteed outcome, the goal is to use strong data, clear written arguments,  and targeted consumer assistance requests to resolve complaints, and to get matters of parity and processing addressed by the insurance company and the employer's compliance department.   If at any time you wish to seek a formal legal opinion, please consult an attorney.