AWC Blog

Why You Need A Patient Advocate

Candace Wenham, MS, BCPA

By Candace Wenham, owner of AdvocATX.com

A Patient Advocate is a medical consultant who can do many things, including finding a great doctor/holistic practitioner, researching and providing you with treatment options, overturning medical insurance denials, communicating with medical staff as your voice, accompanying you to appointments, providing you with questions to ask, investigating your prescription side effects and interactions, listening to and helping guide you during emotionally difficult times, and generally improving the quality, and quantity, of your life.

As a private Board Certified Patient Advocate, I am here to help you live your best life and will support your physical and spiritual wellness.

Here are some examples of adversity and how I can help:

Perspective Problems

A client had severe high blood pressure (hypertension). She was taking eight prescriptions, most of them for hypertension. She had been hospitalized and given an angiogram (a test to evaluate the health of the blood vessels near the heart), yet nothing could determine the cause of her angina (chest pain) and high blood pressure.

They released her from the hospital on several occasions, without providing relief from her chronic hypertension, with a diagnosis of congestive heart failure. She began swelling all over and complained to doctors that she was feeling out of breath, had trouble sleeping, restless leg syndrome, and more.

They continued to prescribe more medications to counter the side effects of other medications, yet none of these ever solved any of her problems. Her blood pressure continued to remain high, she gained twenty pounds of water, and felt miserable.

I stepped in and found her a new doctor, a DO with an in-house acupuncturist and Chinese herbalist. At her first appointment, they were stunned at her physical appearance: swollen, miserable, and tired. She hadn’t slept in years, due to not being able to lie down properly because the medications she was taking were making her condition worse. Her doctor had literally given up on her! Her new doctor noticed all of these issues immediately, and the client was given acupuncture that day. Her blood pressure went from 200/100 to 120/80 within one hour. It has remained normal ever since, after six months. She is off all of her eight prescriptions, she takes Chinese herbs for her swelling (she has lost 20 pounds) and feels amazing. She can sleep, breathe, and eat without gaining weight.

She had so many metabolic issues that were being overlooked by her doctor, sometimes one needs fresh eyes to look at their condition. It is scary to think that a doctor, who is supposed to be making you better, is actually making you worse. We blindly trust doctors, though we should not. This happens every day and is the reason why we all need a patient advocate at some point.

Cancer Returns?

One of my clients had a neuroendocrine tumor, a rare type of cancer, in her stomach and small intestine (the beginning of the small intestine, the duodenum). I researched treatments and their outcomes, and accompanied her to surgeon appointments, asking questions and gathering information. She had the surgery to remove tumors in her stomach, duodenum, and the adjacent lymph nodes. No treatment was indicated, except to monitor blood levels of a tumor marker, Chromogranin A, after surgery. 

After healing from surgery, her oncologist began testing her levels of Chromogranin A (a neuroendocrine tumor marker that increases when tumors are secreting this chemical). In the meantime, I discovered, simply by reading each medication’s consumer information, that her prescription proton-pump inhibitor, Dexilant, specifically causes a false positive of Chromogranin A (leading to the incorrect assumption that her cancer had returned). Her oncologist was stunned when he read the information about Dexilant. He was not the prescriber, nor was he aware that Dexilant affects a very specific neuroendocrine tumor marker. Her Chromogranin levels had been up and down, and once she was taken off the Dexilant, her Chromogranin levels returned to normal, and could be properly utilized to determine whether her cancer had returned.

Denied Coverage

Another of my clients was a teen girl, diagnosed with bipolar disorder at age 15. The girl had been prescribed Seroquel and Klonopin for anxiety and sleep issues, as well as mood control. She was not improving, and her mother continued to take her to a psychiatrist who continued to prescribe these drugs, just changing the amount of either one, but never finding the correct dosage.

The girl never improved, became severely depressed, was absent from school every week, and was causing major turmoil at home. The family became increasingly despondent, due to the problems with the teen girl. She finally had a breakdown and became psychotic. She was hospitalized for eight days, then sent to outpatient care. She continued to cause problems at home, and her medications were shifted again. The mother pushed to get her daughter into a residential home, yet her health insurance denied the treatment. The mother knew her daughter needed intensive treatment, or she may commit suicide.

I was hired to help with the insurance denial. After contacting HR at the father’s workplace, they were told there was a legitimate problem with the insurance. The residential treatment center was told that she was enrolled in another program, that she never enrolled into. Not only was there a mistake on what outpatient program she was attending, but there were also conflicting diagnoses by two different psychiatrists, the first of which denied the girl needed follow-up care at all. Her second doctor, the doctor who knew better, recommended residential treatment, but was not the doctor the insurance was in contact with. We had to straighten out the issues.

First, we contacted the rogue outpatient program that she was not enrolled into and got confirmation on this to give to the insurance. Once this issue was straightened out with both outpatient programs and insurance, we could tackle the rest. The second issue, the two conflicting diagnoses (one diagnosis determined she was fine, the other was exactly opposite), was straightened out by the second doctor himself. He was gracious enough to contact the insurance company and speak directly to doctors making decisions for insurance, knowing the girl needed residential care. He was able to change the initial diagnosis to a more serious, acute disease that needed acute care (residential treatment).

The cost of treatment out of pocket would have been $30,000, but once I straightened the denial out, it was covered at 100%!

Most of the time, if insurance covers something and it’s getting denied, we just need to figure out what is hindering the process. It is usually something easy to fix, once we know what the problem is. Insurance isn’t always bad, they just have to follow very strict protocols. The easiest way to overturn an insurance denial is to be nice, find out exactly what is getting denied and why, and communicate with medical staff, HR (if provided by company), and insurance directly.

In Conclusion

A Patient Advocate can help with so many issues, whether its insurance denials, prescription interactions, incorrect diagnoses, miscommunication between doctors, prescription side effects, miscommunication between doctor and patient, and many other issues that happen in medicine.

A patient may not know how to communicate with their doctor in an effective way. Many patients may feel intimidated by their doctor, and feel helpless at their appointments, not realizing they are in control of their fate. With a Patient Advocate, one can feel confident they are getting one on one care without any conflicts of interest that might be present with an advocate working for a hospital or insurance company.

Private Patient Advocates want only the best outcomes for their clients, and improving healthcare is a primary focus. Providing insight into disease and treatment options can empower a patient and enhance positive outcomes. Fluid communication between doctor, patient, and medical staff is key to allow understanding and insight for the patient, and can enhance medication and lifestyle compliance by the patient. If the patient is aware and can understand how their medication will and might affect them, leaving the lines of communication between doctor and patient open can enhance positive outcomes for everyone.

A Patient Advocate is like having a best friend who is a doctor to guide you through your diagnosis, your options, “doctor speak”, and how to get what you need out of your doctor. If a medication is not working, or you’re noticing side effects, sometimes not for several months after starting, speak up! Your doctor cannot read your mind and is only human. A Patient Advocate can fill in those gaps and alleviate suffering. A Patient Advocate can be your voice when you feel your voice is not being heard. A Patient Advocate can help guide you through difficult and emotional times and will support your choices throughout.

— Candace Wenham, MS, BCPA

Visit AdvocATX.com for more.

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