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What Does Health Plan Member Advocacy Look Like in Action?


At Carenet Health, we offer advocacy, navigation and concierge services to health plans that want to help guide members through their plan engagement and overall healthcare experience.

Health plans typically offer these services to members to help with care coordination and healthcare system navigation, and to help boost utilization of benefits and cost-saving opportunities for the member and the plan.

Advocates can serve as a one-point-of-access support for members and as a personal and human connection to understanding benefits and finding answers. When advocacy is done well, it builds member trust and reduces confusion and frustration. It also helps direct consumers to the most appropriate care and resources.

It’s a type of healthcare concierge service that’s growing in importance. The Physician Foundation 2019 Survey of America’s Patients found that half of today’s patients say they’re confused when they try to navigate the healthcare system. Also, in a recent health literacy update, federal government studies show that about 50% of healthcare consumers don’t move forward with necessary care or wellness action if they hit a perceived roadblock. Health advocates and navigation experts can remove those roadblocks and empower health plan members.

To demonstrate how health advocacy works, here are two examples of Carenet Health advocates “in action.” Please note that names have been changed for privacy.

31 calls, 5 faxes, 2 emails and 1 big sigh of relief

Stephanie was frustrated after receiving a large bill for lab services she thought were covered by her plan and needed assistance with gathering the proper medical records needed for an appeal submission.

 Her advocate discovered the claim was denied due to a lack of information from Stephanie’s provider that would substantiate the claim as medically necessary. The advocate contacted the provider for required records, guided Stephanie through release authorization, verified the legitimacy of confusing requests for additional information from an unfamiliar provider partner, made outreach calls to collect the missing information—and eventually was able to confirm that the health plan had received all records from the hard-to-reach records provider. The Advocate also requested a hold on lab billing during the claim appeal, so the past-due communications would stop.

 The advocate’s determination to overcome obstacle after obstacle saved Stephanie hours of frustration, time and energy, and helped her breathe a sigh of relief.

New, trusted relationship leads to more member help and savings

After her advocate helped her with a complex records navigation issue (noted in above example), Stephanie turned to him for help with another situation—a suspected overcharge and need for reimbursement from her provider.

 The advocate confirmed the provider charged the full costs of four claims to Stephanie (which she paid) without applying any of her benefits. Yet the provider had received the EOB remittance for those claims.

After several emails and 12 phone calls, the advocate was able to work with the provider on a reimbursement. But when Stephanie received the check, the amount was incorrect by nearly $100. The advocate then contacted the provider again and arranged for the additional reimbursement check to be overnighted to Stephanie immediately.

 Stephanie was once again grateful for the assistance—and the $238 back into her bank account.

How can we help your health plan?

Please reach out if you’d like to discuss ways to offer this kind of assistance to your members.