A Medical Insurance Advocate (MIA) helps individuals organize medical bills and negotiate coverage for medical services before and after receiving care. MIAs can save patients money, as well as pay doctor and hospital bills by organizing preapprovals, fixing billing errors, and negotiating coverage denials. Within the field of patient advocacy, there are different roles that each professional fulfills. Some advocates assist with taking patients to appointments, others help families transition into elder care facilities, and still others fix billing errors and appeal denials. Advocates should be transparent about their scope of practice, and it is important that an MIA knows when to reach out to other professionals. Although there is no national standardized licensing procedure for MIAs, an advocate’s specialty depends on one’s background. Medical billing advocacy requires knowing medical codes and billing procedures and having a background as a financial and insurance professional. Having the ability to organize and understand personal financial documents helps one recognize medical billing errors.

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In 2012, a group of patient advocates formed the Patient Advocate Certification Board. They created an exam with 125 general patient advocacy questions with the help of practicing advocates; the exam was administered for the first time in March 2018. For the first two years, the exam test takers are not required to have a specific educational background, experience, background check, or other license to sit for the exam. Having an international standard that is recognized by employers and clients is still early in the development stage, especially since the educational requirements to sit for the exam have yet to be determined by the board.

Advocacy

Knowing whom an MIA aligns with ultimately indicates whose rights they are advocating. Insurance companies employ their own advocates, and they frequently speak with the insured and assist their claims, but their advocacy is in the best interest of their client, the insurance company. Some employers keep human resource benefits advocates on staff to help employees with their insurance benefits. As self-insured companies become more common, however, employers will be making the decisions on covering medical needs; these advocates will be thinking about the best interest of the employer.

CPAs are positioned to look at a client’s finances in their totality and be able to identify medical costs that can be written off, as they can often uncover unreimbursed medical expenses. Helping people achieve financial stability requires collaborating with other professionals in different specialties. A CPA may not have the needed background in medical coding to negotiate medical bills, but spotting the need for medical bill advocacy in someone’s finances is the first step to saving money.

Contracting with an MIA can help determine whether the medical costs are reasonable for the treatment provided. An MIA helps lower medical bills in their entirety. MIAs contract with individuals directly and are either paid hourly or as a percentage of billing savings. CPAs have the ability to contract with MIAs through their firms and offer the services an advocate would provide to their clients, or they can merely refer clients with substantial medical bills to an advocate and let them contract with the advocate directly.

Regardless of how good an individual’s insurance plan is, issues regarding payments for health services are bound to crop up. Sometimes the issues are due to misunderstandings about covered services, wrongful billing, double payments, out-of-network services, and claims denials. As clients age, they must navigate the murky waters of Medicare, Medicaid, secondary insurers, and a lifetime of ignored medical bills. In some cases, families have been able to avoid bankruptcy by working with an MIA.

Having an MIA on a patient’s side of the negotiation table can substantially improve the chances of making a deal.

MIAs can provide guidance and support to individuals who are fighting with their health insurance carriers or healthcare providers over medical bills and claims. Simply wading through, organizing, and prioritizing the bills to pick out the discrepancies and potential resolutions can significantly ease the burden. In a year, this author was able to save two clients over $1.5 million in medical bills by negotiating between the health provider and insurance carrier to get the bills covered or written off.

Each insurance plan offers an Explanation of Benefits (EOB) that allows for different coverage. Although the Affordable Care Act made some coverage mandatory, there are still caveats and exceptions to every rule; for example, self-insured policies avoid the costs of mandated care. Medical bills involve deciphering medical codes, relating them to the bills that are received and to the EOB, comparing bills to make sure double or inconsistent charges are not being billed, and negotiating between the providers and carriers to ensure payments are received and accounts are closed. It can be a nightmare when these bills make their way to collection agencies, and there can be three or four parties trying to collect for the same services. Knowing whom to negotiate with can be tricky; in some cases, it requires reaching out to regulators and government officials to ensure that parties are upholding their end of a contract without resorting to extensive legal battles.

Having an MIA on a patient’s side of the negotiation table can substantially improve the chances of making a deal. Millions in medical bills can quickly add up when being mishandled. MIAs engage with individuals who are in a financially, and often physically, vulnerable state. Building a connection in order to understand and correlate healthcare plans with services received and getting them covered is essential. There are times when coverage is not available and seeking out other resources to help pay for medical coverage can be beneficial. MIAs regularly build relationships with local charities and foundations to understand how they can help.

In general, MIAs are constantly working to improve the coverage for services received and balance patients’ interests against those of healthcare providers and insurance carriers. CPAs are positioned to be among the first eyes to recognize a medical billing issue, and in conjunction with MIAs, can help improve an individual’s medical billing finances.

Adria Goldman Gross, FIPC is CEO and founder of MedWise Insurance Advocacy, Monroe, N.Y.