Patient Advocacy For Dummies Cheat Sheet

Being a participant in your care isn’t about pushing your doctor around or being demanding — it’s about understanding that you have a right to safe, accurate, and effective care. Whether you’re paying with insurance or out-of-pocket, you’re investing in a service, and like any consumer, you have the right to expect a standard of quality. The same holds true when you are advocating for a friend or loved one.

Honing your conversation skills

To participate fully in the healthcare experience, you to need continually educate yourself about your condition and possible treatments; keep your records, medications, and treatments organized; and have the time and peace of mind to ask the right questions. You also need to be comfortable speaking up when you have questions, need more information, or disagree with something you've been told.

The best communication is clear, calm, focused, and assertive. The following tips go a long way to helping you be direct and clear when communicating with your care team:

• Speak confidently
• Be specific when providing details about your concerns and symptoms
• Keep your emotions in check
• Be organized
• Be mindful of your body language
• Use assertive language that is strong but respectful

The following tips can help encourage dialogue and participation from your clinical care team:

• Create an inclusive environment where everyone feels heard and valued
• Encourage open-ended questions during the discussion
• Be present and attentive when others are speaking
• Remember to say "thank you" when someone goes above and beyond for you

Using the teach-back method

Understanding informed consent

Optimally, open, detailed, and thorough conversations should happen between you and your care team about all the risks, benefits, alternatives, outcomes, and purposes of any intervention. Only after this conversation should you sign, or acknowledge, the informed consent.

A standard informed consent form has a fundamental framework that includes many of the following elements:

• Complete explanation of the procedure: Healthcare providers must provide to you the important and relevant information about the proposed intervention. In so many terms, this is an acknowledgement of key information (such as what the intervention will achieve, any risks, any complications involved in the administration of it, and possible outcomes of forgoing it).
• Assurance that you understand the information presented: Having the information is one thing, understanding it is something completely different. That’s one reason why consent forms are written in what is referred to as simple language — they avoid medical jargon and the unfamiliar verbiage of the healthcare field to ensure that patients understand the information.
• Freedom to make your own decision about proceeding essentially means that no one is pressuring you to do anything: Sometimes patients feel like they have to make a certain decision or move forward with a certain course of action because they believe it will please their care team, their family, their friends, or someone other than themselves.
• Assurance that you can decide for yourself: If the patient is unable to understand their options, ask questions about benefits and risks, or perform other functions to ensure that they can decide for themselves, individuals — such as a guardian or a power of attorney, who a patient may have appointed to make decisions on their behalf — can consider these factors for them and make a decision. People with significant disabilities, minors, elderly individuals, or individuals with conditions that affect their cognition may have their informed consent reviewed and signed by individuals who have the legal power to do so.

After reviewing all the key elements of an informed consent, having appropriate conversations with your care team to answer all your questions, and considering all the factors on the table, you can make an informed decision.

Picking the best Medicare coverage for your circumstances

Two of the most popular healthcare coverages in the United States are Medicare and Medicaid. Although they are often mentioned together, they are different coverages with different roles.

• Medicare, for the most part, supports older adults, meaning people over 65 years old, as well as people with disabilities.
• Medicaid supports people who have lower incomes, disabilities, young children, and more.

Medicare requirements do not vary from state to state but Medicaid requirements do. It’s possible for someone who has Medicare to also have Medicaid and vice versa because they are eligible for both coverages, such as an older adult who is in the low income bracket. In some instances Medicaid pays for services that Medicare does not pay.

Consider these tips for picking the best Medicare plan for you:

• Evaluate your healthcare needs: Think about the services you use now and what you may need in the future. For example, if you see a lot of specialists, make sure the Advantage plan you’re considering includes those providers in-network. If you know that vision care is important to you, compare the specific benefits each Medicare Advantage plan offers to maximize benefits.
• Make sure your current provider network is covered: Use a checklist of your current clinicians and hospitals and see if they’re covered under the Medicare Advantage plan you’re considering. It can be disruptive to lose access to trusted providers, so double-check this in advance.
• Compare costs and get real about your budget and cash flow: Medicare Advantage plans vary in monthly premiums, deductibles, and out-of-pocket costs. Decide if you prefer lower monthly premiums with potentially higher out-of-pocket costs when care is needed or a higher premium with lower expenses down the line. Make sure to be honest about your financial situation — there’s no benefit in selecting a plan that stretches you beyond your budget.
• Use the Medicare Plan Finder tool: Visit medicare.gov to use the Medicare Plan Finder tool. This resource allows you to compare plans based on various factors that matter to you, such as coverage types and costs.

Navigating the claims process

When you need a treatment or service, such as a medical procedure, your healthcare provider submits an insurance claim to your insurance company requesting payment for the service they provided. Generally, you work with your healthcare provider to receive a service and the claim is filed on your behalf.

You can submit the claim, or your provider can do it. The claim is a formal bill (like an invoice) that outlines information, like your diagnosis (the diagnosis code), the date of service, the procedure code of the medical intervention, and more. From there, your insurance company makes sure all the information on the claim is correct and compares it to your plan, so they can pay for what is covered and bill you for what is not.

If your claim is approved, the insurance pays for the services. If it’s denied, you’re usually sent an explanation of benefits that shows the breakdown of what they paid for and what they did not. You may be stuck with the bill.

To set yourself up for success and to increase the probability of your claim being approved, keep these tips in mind:

• Make sure you understand what your insurance policy says about cover treatments, procedures, and more. Be familiar with what is excluded, what is allowed, and to what limits.
• When you can, stay in network. Staying in-network means utilizing the services of healthcare providers that belong to hospitals and clinics that have agreed to work with your insurance company. If you get treatment from providers outside of your network, you’re out of pocket fees might be relatively high.
• Don’t take no for an answer. If your claim is denied, you have the right to appeal it. Reach out to your insurance company to understand why it was denied, what other documentation might be needed to support a successful appeal, and the time frame in which you need to take action. Ask for an explanation of benefits.
• Make sure that the supporting documentation and clinical information is correct and complete. That means everything from the spelling of your name, to the date the service was performed, and even how it was billed by medical billers. Errors can result in denied claims.
• Heed the deadlines for submitting claims and appeals. If they give you 60 days, that means 60 days. Don’t risk your claims being automatically thrown out because of a time management issue.
• Keep tabs on your claim. As awesome and individual as you are, you are one of maybe millions of claims that need to be processed by the insurance company. If you receive correspondence that you’re supposed to hear back regarding the status of a claim within a certain time frame and you don’t hear back, ask for an update.

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