At resolve we talk to people everyday who are looking for a lawyer to help them with their medical bills. While sometimes their specific situation calls for a lawyer, oftentimes they may be better served by working with a medical billing advocate to lower their bills.
In this post we’ll dive into the difference between a medical billing advocate and a lawyer, and walk through the key things to consider when deciding whether to hire one or the other (or neither).
Medical Billing Advocates
Medical billing advocates are experts on medical bills and the medical billing system on both the insurance and medical provider side.
Types of Medical Billing Advocates
Medical billing advocates will look at the following 4 areas to help lower your medical bills:
Billing Errors: reviewing medical bills for correctness. This can range from charging for services not provided, upcoding, or unbundling to pushing back against balance billing. They’ll find these errors and then fight with the medical provider to have them correct so you’re not paying for anything you shouldn’t be.
Appealing Insurance Claim Denials: If your insurance company has denied your claim, an Advocate can walk through the multi-step appeals process – gathering and presenting the right evidence in the right way to increase the chances of success (and helping you to avoid a paperwork filled headache in the process). They may also be able to identify when a hospital adjusting the codes used could get a claim overturned without having to file an appeal.
Medical Rebates and Financial Aid: Many medical device manufacturers and pharmaceutical companies will offer rebates directly to patients for devices used. Most hospitals also have financial aid policies to help people on lower incomes (and sometimes with larger bills).
Negotiating Prices: We talk about this constantly – hospital chargemaster pricing (the rack rate charged to uninsured patients) are absurd and completely disassociated with reality. Many Advocates can use data surrounding hospital costs, medicare rates, insurance negotiated prices, and usual and customary rates to convince the hospital to accept a lower price. If that doesn’t work, there’s also the potential to file in small claims court to force the hospital to lower their price.
Some medical billing advocates will specialize in one area while others have experience in all four areas and will adapt to your given situation. One is not necessarily better than the other and its important to consider how the advocate fits with your situation (a good advocate should be able to tell you).
Advantages of an Advocate
Advocate pricing is generally lower than attorneys and they deal with medical billing issues for a living. Experienced advocates have often worked through hundreds of cases and will quickly understand the best path forward to lowering your medical bills.
They also have experience navigating the complex bureaucracy of hospital and insurance billing systems and speaking the right language (saying the right things to the right people).
Note that there is no required education to becoming a medical billing advocate. Anyone can represent themselves as such (that doesn’t mean that there aren’t very good advocates out there). There are some organizations that have created standards and certifications to help consumers – such as the Patient Advocate Certification Board. Understanding what certifications a Medical Billing Advocate has can be a useful way to evaluate their experience.
Broadly speaking a lawyer is an expert on the legal system – they understand the laws of the US, state,and locality they practice in (and sometimes other locations). That being said, the laws of our land are incredibly complex, so lawyers (like medical professionals) specialize in specific areas of the law.
Types of Lawyers
Unfortunately medical bill negotiation lawyers generally don’t exist – the type of lawyer that may work for you depends on your given situation. Below are a few of the specialties you might consider:
Personal Injury: if you were injured in an accident and are considering suing someone (usually not the hospital) it may be worthwhile to talk to a personal injury lawyer.
Medical Malpractice: If you are fighting a bill based on a major error on the part of the medical provider (that is – you think the doctor or hospital committed malpractice in their treatment). Note that there is a significant amount of overlap between personal injury and medical malpractice lawyers.
Insurance Litigation: If your insurance company is denying care coverage and you think litigation is the right route to go – consider reaching out to insurance lawyers.
Bankruptcy Lawyer: These attorneys can explore and discuss your options, rights, and protections around bankruptcy.
Consumer Protections Attorney: If you have court judgements or liens related to an outstanding debt or feel like you’re being harassed by a debt collector – reach out to a Consumer Protections Attorney. In general, we recommend consumer protections attorneys as a natural first step to understanding what can be done about outstanding medical bills.
Advantages to Hiring an Attorney
While often expensive, lawyers are experts at navigating the legal system. In fact, medical billing advocates often cannot provide legal advice in a situation as doing so may be the unauthorized practice of law. They can and will use the court system to maximize your benefit.
In addition, attorneys are often trained negotiators – so even if they are dealing directly with hospitals or insurance companies they may be able to help significantly lower their bills (this isn’t to say that Advocates aren’t trained negotiators, however).
Should I Use an Advocate or an Attorney?
The key question to ask when deciding on whether to hire a Medical Billing Advocate or an Attorney is whether or not this is a legal issue.
If you’re dealing with a legal issue – go with an attorney. Generally if you have liens or judgments filed against you, are being sued, or are thinking about suing – this is a legal issue.
If there may be a way to settle this without the courts (either through fixing errors, appealing insurance coverage denials, applying for financial aid, or negotiating directly with the hospital) – you may be better served by hiring an advocate.
If you’re still not sure which way to go – start calling Advocates and Attorneys and asking for advice. They should be willing to spend 15-20 minutes talking through your case and give advice on the best path forward.
Braden founded Resolve after experiencing first hand how unfair the system is for patients. Prior to Resolve, he built and ran Operations for a renewable energy company and then built and ran Product, Growth, and Operations for a VC-funded edtech company. He received his MBA from Dartmouth’s Tuck School of Business and BA in Philosophy from the College of William and Mary. When not trying to lower healthcare costs he can be found outdoors mountain biking, skiing, or hiking with his dog.