Demand grows for help with charges and claims

Oct 06, 2008 (Omaha World-Herald - McClatchy-Tribune Information Services via COMTEX) -- CAG | Quote | Chart | News | PowerRating -- A two-year struggle to settle medical bills from her son's auto accident left Linda Harris with a 4-inch stack of documents, nearly 20 hours spent on the phone and aggravation that still simmers.

At one point, she said, her insurance company said it paid the hospital for a $3,000 bill, but the hospital said it never received the payment and threatened to send the case to a collection agency. The hospital eventually determined the bill had been paid.

"It was a mess," said Harris, who lives near Lexington, Neb.

And that was just one of her problems.

Many consumers face similar headaches with the health care system, but a service called health advocacy is giving a small but growing number of them an edge.

Health advocacy agencies help make sense of hospital charges, deal with insurance companies over claims or figure out why a doctor overbilled them. The companies, which generally are for-profit, even help patients get appointments with high-demand specialists or help them understand a diagnosis.

Demand for the service is growing, which underscores how the health care system has become so complex that consumers require help from professionals just to sort out their bills or understand their coverage.

After an insurance company denied a claim to cover a California girl's blood transfusions for cancer treatment, a health advocacy company persuaded it to approve the claim. Another health advocacy company helped a family determine that its 13-year-old with cerebral palsy was eligible for Medicaid to pay for medical equipment to help him stand.

Though individuals can purchase the service, it's more commonly offered as part of an employee benefits package.

Some employers offer the service so employees aren't spending work time on the phone disputing a hospital charge or a similar problem, said Richard Rakowski of Intersection LLC, a Connecticut-based health care investment company that has researched the advocacy field.

Omaha-based ConAgra Foods began offering the service this year through Health Advocate, a Pennsylvania company. Consumers who call about a diagnosis or medical question speak with a nurse. Questions about insurance claims and medical billing are directed to other specialists.

ConAgra considers the service help beyond what its human resources department can provide. "The purpose is to provide that extra layer of service that helps them navigate the health care system," said Stephanie Childs, a ConAgra spokeswoman.

Health care analyst Steve Findlay of Consumers Union, publisher of Consumer Reports magazine, said patients often lack the time and expertise to contest a denied insurance claim.

Although human resource departments can answer quick questions, he said, they often lack the staffing to provide long-term help. Insurers and hospitals have experts on their end, which puts the average consumer at a disadvantage, he said.

Harris said her family's employer doesn't offer a health advocate service, but she wishes it did. She faced another bill for $700 from a company that provided her son with leg and back braces. The company said insurance did not cover the braces.

After sorting it out with the insurer, Harris discovered that they were indeed covered.

Calling the insurance company left her frustrated because she was transferred between departments and still wouldn't get an answer, or staff members never called back. "I felt like they kept putting me off."

Last fall, she thought her problems were over. She received a hospital lstatement with a zero balance. But about four months later, she received a second $3,000 bill.

After repeated calls to the insurer and hospital, she finally resolved the problem last spring.

Harris said a health advocate might have solved the problems faster by knowing the jargon and how insurance companies and hospital billing offices work.

Health Advocate, the company ConAgra uses, was founded in 2001 by former insurance executives, said Carol Fischer, a company spokeswoman.

Robert Zirkelbach, spokesman for America's Health Insurance Plans, a trade association, said his organization doesn't have an official position on health advocacy services. Insurance companies, he said, strive to provide good customer service.

He said insurers have an internal appeal process for denied claims. The industry also supports the use of independent panels that provide an appeals process for consumers, he said.

Advocacy companies can assist when insurance cases reach that level. California-based CareCounsel filed an appeal to an insurance regulatory board in the case involving the girl who needed blood transfusions. After the appeal was filed, the insurance company reversed its initial decision and provided coverage.

Though health advocacy services were rare a decade ago and are still uncommon, they are growing, Rakowski said. He said there are probably no more than a dozen companies nationally.

Assistance from such agencies has become more important as high-deductible insurance plans become more common, said Tony Sorrentino of the Omaha-based SilverStone Group, an employee benefits consulting company. "When individuals are spending their own dollars, they pay very close attention."

--Contact the writer: 444-1122, michael.oconnor@owh.com

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