A professional to help navigate health insurance decisions, claims, etc?

December 6, 2021 8:41 PM

I would like to hire a person to help me figure out health insurance for myself, figure out medicare stuff for elderly relatives and deal with signing up, and also deal with paperwork on claims/payments/preauth/etc.

I spend so much time on this and still make mistakes, or find out at the last minute that there are deadlines for programs I didn't even know existed -- so "just look up everything yourself" (which requires you to know what you SHOULD look up) or "spend hours calling 800 numbers" aren't answers I'm looking for. I want to pay money to someone who already has expertise, to save myself time and money.

I also find it extremely stressful to deal with health insurance issues, I always feel like I'm going to make a huge mistake that will end up costing thousands of dollars. (this has happened in the past) Between stress being bad for my health, the amount of time it takes me, and the amount of money I have lost to bad decisions or bad information, I am willing to pay a fair bit for this service -- I expect fees might be similar to hiring a lawyer but it seems it would be well worth it to pay someone.

What is this person called? Where do I find them?

It's probably obvious from the question, but I am in the United States.

I have tried to search for previous questions and not found anything relevant -- I would imagine I can't be the first person asking about this here, and I'm probably not finding anything simply due to not knowing the correct search terms. Tips on search terms or links to previous questions are welcome.

I am NOT looking for the 800 number to call about ACA questions. I am seeking in-depth professional advice from someone who will learn about my situation and be able to make recommendations based on their body of knowledge, and help implement those recommendations. Not a "healthcare consultant", which seems to be someone who consults for hospitals and other medical businesses, but a person who works with the individual consumer who is trying to find the best options for themselves and their families.

posted by yohko to Health & Fitness (12 answers total)

An insurance broker would be able to help you with health insurance for yourself. I don't know if they would be able to help with Medicare or claims, but it's a possible starting point for investigation.
posted by likedoomsday at 8:56 PM on December 6, 2021

A healthcare navigator can assist with ACA signups and such.
posted by sageleaf at 9:07 PM on December 6, 2021

Insurance brokers / healthcare navigators can take you some of the way, but they can't help you when the inevitable inscrutable surprise bills and insurance denials happen at some point during the year ahead. They can't help you with extortionate lab fees because your primary care doctor's lab somehow got classed as a hospital outpatient lab.

I always feel like I'm going to make a huge mistake that will end up costing thousands of dollars. (this has happened in the past)

If you have any kind of health issues greater than occasional primary care visits and generic prescription refills, there are no options that will not at some point feel like a huge mistake costing you at least hundreds of dollars. There is nobody who can plan for the consequences of of a random accident with a kitchen knife or a tree root on a hike or whatever.

For Medicare-age people, there are planners. (Ideally ones who'll say that Medicare Advantage is mostly a scam.) For working-age adults, you can perhaps pay a little to reduce the outer limits of risk from five figures to four, but that's as much as can be done.
posted by holgate at 9:57 PM on December 6, 2021

To revise and extend: you can pay people to check the various formularies based on your current prescriptions, but that's if your medications don't have generics, and it doesn't take into account what you might be prescribed in the middle of next year; you could pay people to check the network status of people you already see, but that doesn't take into account who you might need to see in the middle of next year. There is nobody you can hire who can predict your future.
posted by holgate at 10:00 PM on December 6, 2021

My employer used to offer this as a perk and called it a "benefits concierge" - basically someone who worked for our company (crucially, not for our insurance company) and would just spend the time on the phone to track down what happened with your payment or whatever, figure out the insurance conundrum, and tell you what the conclusion was. It absolutely kept me working there through some hard times but it was cancelled recently, I think because the company wanted to be less involved in the details of employees' medical care.

I have no idea if this is something other companies offer as a perk as well, but maybe this is a term you can google to see if you can find anything else like it.
posted by potrzebie at 11:16 PM on December 6, 2021

You might consider asking your parents' PCP if they could refer you to a case manager. This very much falls into the job descriptiom of a CM. Larger hospital system, and some smaller offices, will have acces to a CM.

Another thing you might consider, if you haven't already, is learning tbe fundamental vocab of an insurance plan - terms like copays, coinsurance, deductibles, etc. Sorry if you already know this or if it's too basic - a lot of folks don't know what these terms mean and it causes a lot of confusion. Even I didn't understand these for a long time, and I work in healthcare. It can be empowering to learn what these are and how they work. There are tons of free online resources from google searches like 'how to read an EOB' or 'how American health insurance plans work'. Again, apologies if this is too basic.

As for preauths etc, the prescribing doctor's office should be able to carry these out for you.

I am really sorry you're going through this. (Assuming you are in the US) Our healthcare system is so unnecessarily convoluted, and insurers are often working against the interests of their parents. Your situation is unfortunately not unique, and that is so upsetting. I wish you the best.
posted by aquamvidam at 12:40 AM on December 7, 2021

I have gotten this kind of help from a person with the job title Billing Specialist at a community health center. If you have community health centers that serve lgbtq+ and/or unhoused populations, calling up the appointment scheduling or payments questions phone lines and asking to schedule a meeting with a person who can help you navigate access to healthcare may be a service they provide at no cost to you.

If I remember correctly, this service was open to anyone who planned to get care from the community health center, so if you are already attached to your PCP/reproductive health/STD screening providers this might not work out for you.
posted by All Might Be Well at 9:09 AM on December 7, 2021 [1 favorite]

When I was researching various health plans as an independent shopper, and trying to understand Medicare for my husband, I found an independent health care agent/broker. She is phenomenal. She knows all the different plans available to us in our county, all the networks that they use, which of our local physical therapists and dentists are in-plan, what the premiums and deductibles are, etc, etc, etc.

She handles all the paperwork and sends us what we need to sign, highlighted, if anything.

Highly recommended.
posted by SLC Mom at 10:32 AM on December 7, 2021

I should add that I had complicated questions for the Billing Specialist and he was patient and fantastic and could do things like listen to a description of a problem, find a form online, print it out, hand it to me, call his contact at an organization, then fax that person the form I had filled out. He also called up the state health connector and had memorized which phone tree buttons to press when, and then handed me the phone when I had to wait on hold to be connected to a person.

This was all mid-2010's, post-ACA but pre-COVID. It might be trickier now.
posted by All Might Be Well at 11:14 AM on December 7, 2021

There are companies (Bedsiide, Denials Management, to name a couple) that manage claims if you have a ton or can’t deal with them. Some work on contingency, others for a flat fee. People with complex medical situations sometimes use them.
posted by chesty_a_arthur at 11:54 AM on December 7, 2021 [1 favorite]

Not sure where you are but in Mass, the senior centers have trained people that will explain your Medicare options.
posted by Ferrari328 at 1:49 PM on December 7, 2021

For all things Medicare-related, you can consult your local SHIP.
posted by ruddlehead at 6:21 AM on December 8, 2021