When to Use a Medical Billing Advocate (2024)

Are you feeling overwhelmed by medical bills? Are you having difficulty understanding what all of the bills are actually for and why your health insurance isn’t paying more of them? If so, it might be time to call in a medical billing advocate.

This article will explain what medical billing advocates can do for you, and when you might benefit from working with one.

What a Medical Billing Advocate Can Do for You

A medical billing advocate can analyze your medical bills and spot errors, over-charges, duplicate charges, unreasonable charges, and even fraud. They can figure out whether your health insurance has paid as much as it should have, and if not, why not. They can work on your behalf to get inappropriate charges fixed or to appeal health insurance claim denials.

And even if everything has been coded correctly and your insurance claims have been processed as they should have been, a medical billing advocate may be able to negotiate with doctors and hospitals to decrease what you owe.

Medical billing advocates are hired by the patient to work on their behalf. The amount you'll pay for a medical billing advocate will vary depending on whether they charge an hourly rate—which can range from $75 to $350—or a percentage of the amount by which they get your bills reduced.

When You ShouldHire a Medical Billing Advocate

Consider hiring a medical billing advocate if you’re experiencing any of the following issues:

• You don’t understand your medical bills or the codes that have been used by your medical providers, and the explanations given by your providers don’t make sense.
• You have a significant number of bills (which can happen even from a single complex medical incident), some of which might need to be questioned, and you don't have time to wait on hold with your insurance company or the medical providers' offices.
• You're dealing with a chronic medical condition that involves a steady stream of medical bills, and you don't want to fall behind on managing them.
• Your health insurance is refusing to pay part or all of your medical bills and the reason doesn’t make sense or seems wrong.
• Your health insurance is refusing to pay part or all of your medical bills and is giving you the run-around.
• The hospital billing office (or doctor’s billing service) is blaming things on your health insurance company, and your health insurance company is blaming the same things on your hospital (or doctor’s office). And you’re stuck in the middle, holding the bill.
• You’re overwhelmed with medical bills that you can’t possibly pay and you’re considering bankruptcy because of them.
• You have no insurance and you’re not good at negotiating. A medical billing advocate can negotiate lower bills in advance or after the fact.
• You’re so sick you no longer have the energy to deal with the volume of paperwork required to manage your medical bills and health insurance coverage, but you don't want family or friends to have to do it for you.
• You’re responsible for managing the medical bills of someone else (perhaps an elderly parent) and either can’t make sense of them or are overwhelmed by what’s involved with keeping track of them.

What the Advocate Will Need

Exactly what tools and information a medical billing advocate will need to help you depends on the particular circ*mstances of your medical bills and health insurance plan. However, you should expect that he or she may need at least some of the following:

• Your medical bills.
• Your health insurance information, as well as details about any secondary or supplemental insurance coverage that you may have.
• Your explanation of benefits (EOB) forms.
• Your permission to speak with your healthcare providers and your health insurance company.
• Access to your medical records.
• Information about what you’ve paid already.
• Information about what steps you’ve taken to resolve the issue prior to getting the medical billing advocate involved.
• To be paid. Medical billing advocates don’t work for free; however, they'll likely save you a lot more money than they actually charge, so their services are typically worth it.

Finding and Hiring a Medical Billing Advocate

You can find medical billing advocates using the AdvoConnection directory. And you'll also want to check with your employer's human resources department; some employers provide medical billing advocacy services as part of their benefits package, either for free or at a reduced rate.

You can learnmore about patient advocacy from a patient advocacy trade group theAlliance of Professional Health Advocates.

Once you've found some candidates, learn ​how to interview and choose a patient advocate.

You may also find that a consumer advocacy organization in your state can provide zero-cost assistance with your situation, depending on the medical billing problems you're facing. The Colorado Consumer Health Initiative's Consumer Assistance Program is an example of this, and there are similar organizations in other states.

Summary

A medical billing advocate works on behalf of a patient to help them understand, negotiate, and reduce their medical bills. A medical billing advocate can be particularly helpful if a person has a lot of bills, a complicated medical situation, or inadequate health insurance. Medical billing advocates can charge an hourly fee or a percentage of the amount by which they get the medical bills reduced. And some employers provide medical billing advocacy as part of their benefits package.

A Word From Verywell

If you're facing overwhelming medical bills, a medical billing advocate might be the solution you need. But you'll have to pay for their services. So it's also a good idea to check with the hospital or medical facility to see if they have a social worker who can help you, or to see if your employer's human resources department can offer any assistance. If you enrolled in your health plan with the help of a broker, they can provide assistance if you're struggling to understand your medical bills.

By Elizabeth Davis, RN
Elizabeth Davis, RN, is a health insurance expert and patient liaison. She's held board certifications in emergency nursing and infusion nursing.