The Patient Advocate deciphers medical billing

Just a few years after launching a company to help doctors run the business side of their practices, Springfield businessman Don Tucker saw an opportunity to start a second venture aimed at helping patients.

Tucker launched Focused Physicians Inc. in 2006, helping physician practices with scheduling, medical record coding, billing, claims, collections and accounts receivable.

In August, he opened The Patient Advocate LLC after his Focused Physician work shed light on a widespread need among patients for help navigating the billing maze.

"A lot of elderly people struggle with their medical bills, sorting things out," said Tucker, who has been in health care administration for more than three decades. "If you have a hospital stay, you'll get a bill from the hospital (and) a bill from every specialty physician you see. So you're inundated with medical bills."

The Tuckers are in the process of relocating both ventures to leased space in Butler, Rosenbury & Partners Inc.'s 319 N. Main Ave. building in downtown Springfield, from 1135 E. Lakewood St.

Breaking down bills

Six contracted case managers at The Patient Advocate, led by Tucker and his son, Michael, vice president of operations, make sure clients understand what their insurance is responsible for covering and how much they need to pay out-of-pocket.

"(Clients) come and bring their shoebox with all of their bills ... and we'll go through and sort those by providers, by dates of service to get a clear understanding of what is involved," said Michael Tucker, who has worked in medical billing for nearly 20 years. "Then ... we'll come up with a summation to the client of what we see to go forward." And if there are questions that need to be answered, he said case managers will call and get the information.

Advocacy is not new in health care, Don Tucker said, noting that doctors, hospitals and insurance companies sometimes answer patients' questions.

For example, Springfield-based Employee Benefit Design LLC offers its clients access to assistance through an independent company, Health Advocate. The fee-based service is available with favored pricing because EBD is a member of United Benefit Advisors, said Alecia André, EBD account manager.

"It will handle any type of medically related service," she said, pointing to finding providers, making appointments and answering benefits, billing or medical questions. "When the doctor talks real fast and shuffles you out of the office and you don't understand what's going on, you can call Health Advocate, and they'll help piece together the information that you need to make informed decisions," she said.

Dr. Thomas Brooks, a pain management specialist with CoxHealth and former client of Focused Physicians, often fields patients' billing questions - sometimes even related to other providers - and has referred patients to The Patient Advocate.

"I'm not a billing expert by any means," Brooks said, adding that it's important to find help from somebody who can look at the whole scope of a patient's insurance package and address questions. It's essential that patients understand what's covered - or not - by their insurance, he said.

"Physicians' offices are overwhelmed with different policies," Brooks added. "Having somebody who has an expertise in that area to guide the patient, I think, is a fabulous idea."

Access to assistance

Right now, The Patient Advocate operates on a fee structure that starts at $50 for physicians' bills and ranges up to $100 for bills related to a hospital stay, Don Tucker added. He declined to say how many clients have been assisted since opening in August, but he said the plan now is to convert The Patient Advocate into a not-for-profit entity. Doing so, he said, would open the door for financial assistance for patients.

"I have visited with (Congressman) Roy Blunt's office (which has) an advocate for Medicare. They ... offered us all kinds of information about government programs, if we wanted to apply for a grant to help fund this service, rather than do it on the backs of the people who need it," Tucker said.

Sometimes, in the process of examining client bills, case managers are able to alleviate the burden of medical bills, by uncovering instances of over-billing or double billing, or by matching patients with available government assistance.

But reductions aren't a given.

"There are times when we'll go through (the process) and say, 'You know what? You've got a $2,000 bill, and you owe it," Michael Tucker said.

While turning a new business into a nonprofit might be unusual, Don Tucker said, it benefits several parties, including Focused Physicians, as it helps its eight client practices streamline billing and claims.

"If you don't understand a bill, you're not going to pay it, so we're everybody's friend," Tucker said. "We want the hospitals to get their just due. We want the doctors to get their just due, and we want the patient to be treated fairly."