PROGRAM HIGHLIGHT: PATIENT ADVOCATE FOUNDATION

The Patient Advocate Foundation is a national non-profit organization that seeks to safeguard patients through effective mediation assuring access to care, maintenance of employment and preservation of their financial stability. Established in 1996, they mediate with insurers, employers and creditors when the crisis is related to life threatening or debilitating diseases, partially in an effort to avoid litigation. Eligibility mainly entails having a serious illness not caused by injury (e.g., not spinal cord injury, not caused by a motor vehicle crash) and the need for ongoing medical care (they generally do not cover dental care unless related to overall health).

PAF’s case managers and attorneys act as liaisons between a patient and their insurer, employer, and/or creditors to resolve insurance, job discrimination and/or debt matters relative to their diagnosis. Direct patient services include negotiating pre-authorization approvals; mediating insurance denials, appeals, and billing problems; researching financial resources to supplement insurance and provide access to health care for the uninsured; negotiating access to pharmaceuticals, chemotherapy, medical devices and surgical procedures. Some examples follow.

Debt Crisis Intervention

Cancer patients and their families often find themselves in economic crisis. Loss of income, cost of therapy and the general upset within the family can take its toll. Case managers might work with the patient/family to work out a payment plan with the creditor or the Case Manger might negotiate a discount with the creditor. Patient Advocate would look for specific funds available in the community for financial relief and/or give the client information about how to do fundraising to deal with their expenses.

Prior Approvals or Coverage Refusals

In addition to helping patients understand their coverage, Patient Advocate Foundation staff will also advocate with insurers to try to gain coverage of procedures or treatments that have been refused and to help clients navigate appeals processes. A specific example might be to advocate for coverage of a drug for off-label use.

The Co-Pay Relief Program

The Co-Pay Relief Program (see www.copays.org) is a sister organization that provides financial assistance to needy patients with health insurance and certain diagnoses to help them pay for needed prescriptions and/or treatments. Income eligibility is about 400% of FPL (currently $39,200/year individual, $80,000 for a family of 4). This group includes those facing the Medicare D “donut hole”. Funding for this program is by diagnosis, so eligibility is also diagnosis specific. To qualify the applicant must have one or more of the following:

Assistance may also be available to patients who are experiencing secondary issues as a result of cancer treatment.

Those who receive assistance can get up to $2,500 per calendar year for co-pays for any type of medication including chemotherapy. Applicants can qualify under more than one category at a time and access that additional pool of money. Assistance is generally paid to the medication provider.

The application process, however, requires patience, and is distributed on a first-come, first-served basis. Applicants must call a toll-free phone number. They only accept applications starting on the first Wednesday of the month, at 11:00 a.m. Eastern time, until that month’s allotment is dispersed. Applicants who can’t get through before funds are depleted can try again in subsequent months. Assistance can “look-back” for 12 months. The phone number is: 866-512-3861.

Additional Programs

PAF awards 10 “Scholarships for Survivors” yearly to students whose studies were interrupted or delayed by a diagnosis of a life-threatening, chronic or debilitating illness.

For more information see: www.patientadvocate.org. The Patient Advocate Foundation meets the BBB Wise Giving Alliance 20 Standards for Charity Accountability. See the full report at: http://charityreports.give.org/Public/Report.aspx?CharityID=2040.

10/06