How to choose a patient advocate: the questions, the credentials, the red flags

There are thousands of independent patient advocates in the United States and no license required to be one. Many are excellent: former nurses, social workers, billing specialists and hospital administrators who know exactly how the system fails patients and how to make it work. Some are not. Because the profession is unregulated, the vetting is your job, and this is how to do it.

Private advocates cost $100 to $250 an hour and are worth it for the right problem. Before hiring one, check whether the help you need already exists at no cost:

• A problem during a hospital stay: the hospital’s patient representative or ombudsman, free and immediate.
• A Medicare coverage, enrollment or appeal question: your state SHIP, free and expert. 1-877-839-2675.
• A disease-specific need: many disease organizations employ free navigators and run assistance funds.
• Ongoing coordination of a Medicare patient’s care, appointments, equipment, benefits and follow-ups: Medicare-covered navigation through Community Health Integration or Principal Illness Navigation, which is what Navigate Care provides, at $0 for most patients.
• A dispute with your own insurer: the insurer’s member advocate line and, if that fails, your state insurance department.

A private advocate is the right tool when you need someone who answers only to you, especially in a dispute with the health system itself; when you need in-person attendance at appointments; for a complex bill audit or a high-stakes appeal; when the patient does not have Medicare; or when the free options have been tried and were not enough.

• Board Certified Patient Advocate (BCPA). The only independent certification, from the Patient Advocate Certification Board, requiring an exam and continuing education. Not a guarantee of quality, but a meaningful signal. Verify at pacboard.org.
• Clinical background (RN, NP, MD, LCSW, PharmD) matters for advocates who will interpret medical information, attend appointments, or help with treatment decisions.
• Billing and coding background (CPC, medical billing experience, hospital revenue cycle) matters for bill audits and claims disputes.
• Insurance or hospital administration experience matters for appeals and system navigation.
• Elder care experience, including geriatric care management (Aging Life Care Association membership), matters when the client is an older adult with multiple conditions.
• Match the background to the problem. A brilliant bill advocate is the wrong person to attend an oncology consultation, and vice versa.

Most advocates offer a free 20- to 30-minute consultation. Use it as an interview.

1. 1.What is your background, and how many cases like mine have you handled?
2. 2.What is your hourly rate, and do you bill in 6-, 10- or 15-minute increments? Do you charge for phone calls, emails and travel?
3. 3.Based on what I have described, what is your estimate for this case, and at what point will you tell me we have reached it?
4. 4.Do you offer flat fees or retainers, and for what?
5. 5.Do you carry professional liability insurance?
6. 6.Can I speak with two or three past clients?
7. 7.How do you communicate, how quickly do you respond, and what happens if you are unavailable?
8. 8.Do you have any financial relationship with any provider, facility, product or insurer? (The answer should be no.)
9. 9.What will you not do? (A good advocate has clear limits: no medical advice, no legal representation, no guarantees.)
10. 10.What does the written agreement include, and can I see it before deciding?

Get it in writing: scope of work, fee structure and increments, estimate and check-in points, what expenses are billed, how and when you are invoiced, confidentiality and HIPAA authorization, how either party ends the engagement, and what happens to your records. Read it. Ask about anything unclear. A professional advocate expects this.

• The Alliance of Professional Health Advocates directory (advoconnection.com), searchable by location and specialty.
• The National Association of Healthcare Advocacy (nahac.com) member directory.
• Greater National Advocates (gnanow.org).
• The Patient Advocate Certification Board’s list of BCPAs.
• The Aging Life Care Association directory, for geriatric care managers.
• Referrals from a hospital social worker, an elder-law attorney or your Area Agency on Aging, who know the local field.