Public Education

~How Do I Hire a "Live-In" ?

~Questions for Interviewing Potential Caregivers and Useful Observations

~How To Choose A Senior Living Arrangement

~Care Managers Emerge As New Force In Helping

~'Can We Talk Price?'

~Paying Someone Else to Talk Back to Your Doctor

 

 

How Do I Hire a "Live-In" ?

Hiring an individual to monitor and care for a loved one in his or her own home is a complex decision. Many choices need to be carefully weighed to ensure the health and safety of the person needing the care. Many questions need to be answered as you move along the process.

Weigh the Pros and Cons

• A Live-in is not always the least expensive route. Evaluate the different options and the costs involved.
• Evaluate the social isolation factor. Social isolation can lead to and increase depression. Who can visit and how often are important questions to ask.

How Do We Pay For It?

• Medicare does not pay for "custodial" or routine daily care. Medicare only provides for short-term, intermittent care for an illness. For example - Medicare may provide for a daily bath while a person recovers from a fractured hip.
• Some long-term care policies do pay for in home care but there are usually restrictions. They may require you to use a licensed, bonded and insured agency. It is usually not possible to get insurance reimbursement for individuals that are paid in cash or when no social security is taken out of the paycheck.
• Live-in care is most commonly an "out-of-pocket" expense.

What Does a Live-in Cost?
Prices range from $85 to $200 a day. The less expensive services usually require cash payments and the individuals may not be legally able to work in this country. The more expensive services are usually licensed, bonded, and insured agencies with 24-hour emergency on call systems.

How Do I Find A Live-in?
There are several ways to hire a live-in:

• Advertise in local papers and word of mouth. You can screen and chose the worker that suits your needs.
• Ask for a referral list from a health care provider such as your physician, home health agency, hospice, etc.
• Referral agencies - these usually charge a finder’s fee to both the client and the worker. Frequently they have satisfaction guarantees if the placement is not successful. It is important to understand that they are a finder agency only and the employment relationship is between you and the employee.
• Employment agencies that maintain a relationship with the worker and the client - they bill for the services through the agency and pay the worker accordingly. Most of their employees are independent contractors (1099 employees). This results in limited insurance, bonding and health care regulation. Some agencies will do background checks and verify Social Security status, provide orientation, training and supervision of employee.
• Nursing agencies - the agency is licensed by the state in which they provide services. They are regulated and inspected by the appropriate state agency. They usually are bonded and insured which provides further protection to the client. The caregiver is employed by the agency not the client. Again, this limits the client’s liability. The agency usually has a 24-hour on call emergency service. They are responsible for finding alternate caregivers if there is a caregiver failure. This is the most expensive caregiver arrangement. The agency incurs high costs in payroll taxes, insurance, and administration.

What Can I Expect a Live-in to Do?

• A Live-in is generally an unskilled worker with on the job training and/or certificates in basic care such as feeding or bathing.
• They are usually able to provide basic care of bathing, feeding, toiletry, etc. If special procedures are needed for a client such as tube feeding, they need to be specifically trained for that procedure.
• They can take care of such tasks as housekeeping, laundry, food preparation and shopping for staples.
• They act as a companion and accompany the client to appointments. They do not always make good advocates for the client because they sometimes lack the skills and sophistication to assist with complex medical choices.
• They usually do not drive and alternate transportation needs to be arranged.

How Long Do They Work Each Day?
No one can work 24-hours a day. Live-ins need rest. Most Live-ins work 10 to 12 hours a day. If a person requires 24-hour active care, more than one caregiver is required. This "relief" caregiver can be a hired person, a family member or friend. Planning regular scheduled time off for the Live-in reduces the risk of burnout. Some agencies assist in providing relief staff.

What Are Some of the Drawbacks of Live-Ins?

• A Live-in needs to be monitored. They often lack the knowledge and skills to develop appropriate plans of care without guidance from the family or a trained professional.
• In our opinion, money management responsibilities of a live-in should be limited. Financial abuse is common in the unsupervised live-in situation.
• A Live in needs help from the family or trained professionals to make medical assessments.
• If the Live-in becomes ill or has an emergency, the client can be left unattended without warning. This can wreak havoc on the family.
• You can have personality clashes between the client and the Live-in. This may require a change in Live-ins that can be costly and time consuming.
• Even though you have a Live-in, your loved one can be socially isolated. The illness or disability may make it too difficult to get out of the immediate environment.
• Language barriers and cultural misunderstandings can also be difficult to overcome.

How Can Care Management Help?

• Care Managers are trained professionals with experience in community resources. They can help you sort through your options and develop a plan that is best for all parties involved.
• They can help you screen and choose caregivers and agencies. They know how to access public health records on agencies and can identify agencies with deficiencies.
• Care Managers can develop and monitor a professional plan of care for the client. This plan of care can be broken down step by step for the Live-in to follow.
• Ongoing monitoring and modifying the plan of care provides a more successful outcome. Adjustments in the plan of care are necessary as the situation changes and all situations change.
• Care Management is available for crisis management. Early intervention prevents the escalation of a problem.
• Care Management can offer day-to-day money management to help limit access to money and safe guard against financial exploitation.

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Questions for Interviewing Potential Caregivers and Useful Observations

• Tell me about your experience as a caregiver
• Have you worked as a Live-in caregiver before? If so for how long/for how many different people?
• Are you looking for a long term or short-term assignment?
• What types of medical problems have you worked with?
• Have you worked with_______patients before? (stroke, Alzheimer’s, dementia, brain injury, pediatrics, terminally ill, paralyzed, heavy-set people, etc.)
• Do you use a gait belt to transfer people? (if applicable)
• Do you have a car and driver's license?
• Can you cook? What type of meals do you prepare?
• Are you willing to go grocery shopping and/or run errands for the client/family?
• Do you require time off? If so, how much? How often? Can your time off be on a routine schedule (i.e., every third Saturday; the last weekend of every month?)?
• Can you provide written or phone reference(s) for the last person(s) you worked for?
• Why did you stop working your last assignment?
• Do you drink? Do you smoke?
• Do you like dogs/cats? (if applicable)
• Do you have a mobile phone? Do you have a call card if you need to make long distance calls?
• How well do you read/write English? (If this is or may be an issue)
• How do you fell about a representative (family) stopping by to talk to the client/family and check on how everything is going with them?
• Will you agree to call the representative (family) first if you have ANY problems or concerns about the client/family/situation? (Do you understand that the representative (family) is here to help?)

Observe:

• Does the caregiver seem to have a complete understanding of English?
• Is the caregiver able to answer questions using clear, easily understood English?
• Do the answers seem thoughtful and sincere?
• Do the described experiences of the caregiver seem to match with the needs of the client/family?
• Does the caregiver’s personality style appear a good fit with the need/desires of the client/family?
• Does the caregiver describe past care/work experience in a positive fashion?
• Is the caregiver eager to give a reference or more than one reference?
• Does the caregiver seem to want to take direction and guidance in doing the job to the client/family’s satisfaction or does s/he seem more wanting to come in and “take over”?
• If the caregiver speaks of needing time off does s/he then comment on/ offer/ suggest that a replacement can/will be arranged by the agency? (This may evidence realization of the importance of dependable 24 hr. care coverage)

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HOW TO CHOOSE A SENIOR LIVING ARRANGEMENT

Patricia Cline MSW, LCSW, RG
Senior Care Manger

With the increasing number of Nursing Home, Sheltered Care, Assisted Living, Life Care and Retirement Housing options available, the choice process may seem overwhelming at times. It is reassuring to note that an increase in the types of options available does result in an improved ability to match an individual’s care needs and personal preferences to a "new" living arrangement. Much information is available; the questions become those of what information to look for and where.

Over recent decades the amount and type of information that can be easily accessed has increased exponentially as a result of technology. Today most agencies, such as the State Departments of Health, State Departments of Human Services, Federal Administration on Aging and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), have web site and/or toll free phone access. This type of access allows for a streamlined means of gathering information that has, in past times, been relatively cumbersome to access. Because senior living arrangements such as Nursing Homes and Assisted Living are increasingly subjected to governmental regulation and review, a great deal of information can be accessed from these sources. It is important, however, to realize that such data is only one factor among many to take into consideration in choosing appropriate living arrangements for a loved one.

Please view our resources/links page, as there are numerous "How To" links listed. The following is a brief summation of some of the information available there:

CHOOSING NURSING HOME CARE:

• Personal tours and visits are the most helpful. Sometimes visiting without a prior appointment can yield more insights than a pre-arranged tour. Prearranged tours do, however, provide more of a guarantee that staff will have sufficient time to spend with you. Utilizing both types of visits to a facility you are seriously considering is advisable. During visits observe the following:
• Atmosphere: Should be physically pleasant, clean and free from odors; Safety equipment such as handrails and fire-extinguishers should be clearly visible; The attitude of staff members should be positive and convey an emotionally pleasing presence; The facility should appear to have adequate staff to care for the number of residents.
• Management: Persons with supervisory responsibility, such as Administrators, Assistant Administrators, Nurse Managers and Department Heads, should be observed as active in the overall operation of the facility, and should indicate willingness and availability to assist families as well as staff; these individuals should have geriatric and healthcare backgrounds and experience.
• Services: Type of care provided should be consistent with that needed by your loved one, i.e., if you are seeking care for stroke, Alzheimer’s, Physical Rehabilitation, etc, the facility should have other residents with these same issues; Meals and activities should be attractive and appropriate; Community involvement, such as visiting entertainment, religious services and library services, should be included.
• Residents: The residents in a facility should be observed as participants in their care; Individuals should appear clean and appropriately dressed; Interactions between staff and residents should appear respectful and individualized; Residents should be participating in activities that appear appropriate and enjoyable.
• Published information should present a view that is consistent with the impression obtained during the personal visit and can be useful in comparing facilities in the areas of services offered and costs. A personal visit to the facility should measure up to images and claims present in any of the facility’s brochures and marketing media. Published State Inspection results for the most recent inspection are required by law to be readily available at the facility. Historical inspection results may be available on-line.
• Any published information regarding specialized services, such as Physical Therapy and Rehabilitation, Alzheimer’s and Dementia care or personal services should be able to be verified as accurate during the visit to the facility.
• Information regarding daily rates and fees for additional services should be clearly written and comprehensive. Any questions regarding published fees and costs should be asked and the facility should have knowledgeable staff available for answers. Questions about Medicare and Medicaid coverage of services may be generally mentioned in the facility’s brochures, and staff should be able to explain the details, as these are sometimes complex.
• The most recent State Inspection results should indicate few if any deficiencies, and any deficiencies should have clearly stated means of correction.

• Community reputation and information obtained from current or recent families of residents can provide a great deal of insight into the overall quality of a facility. While no two consumers have identical experiences, a consensus of opinion from a number of consumers is most often reliable.

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Care Managers Emerge As New Force In Helping

 

Article By: Linda Greider
Published in: AARP, December 2001, Vol. 42 No. 11, Washington D.C. p 9-13.

When Hugh McGuire made a business trip to the Chicago area, he decided to visit his wife's 90-year-old aunt and 88-year-old uncle, who lived nearby in their own home. 

What McGuire found alarmed him.  While the couple was still ambulatory and proud of their independence, there was no food in the house and the formerly fastidious couple were no longer taking care of themselves or their home.

Like a growing number of Americans taking care of aging relatives from afar, McGuire responded to the situation by hiring a geriatric care manager, a relatively new type of professional who helps plan and organize care for disabled elderly people.

More and more people "are learning that geriatric care managers are out there and that they can help with these problems," says Erica Karp, who runs a geriatric care management firm in Evanston, Ill.

She was able to help McGuire's relatives by arranging meals for them, straightening out their legal affairs and eventually finding placement for the wife in a nursing home, where Karp continues to visit her regularly.

McGuire's situation is hardly unusual. At least one in every four American families provides care for an older relative. Many live hundreds of miles apart, compounding the stress and concerns of caregivers.  How can they be sure their relative is not refusing to eat or misusing medications or mismanaging finances or feeling depressed?

Family members may also face tough decisions—such as choosing between assisted living, home care or a nursing home—which may be complicated by a limited knowledge of available options.

Geriatric care managers aim to help families in these circumstances.  They may be hired either by family members or individuals needing care.

While care managers aren't regulated by state or federal government, they're usually licensed in a field of specialization, typically social work or nursing.  That means most care managers are subject to disciplinary action by a state licensing board should a violation of standards occur.  Technically, however, anyone can hang out a "geriatric care manager" shingle.

Even so, more care managers are joining groups like the National Association of Professional Geriatric Care Managers (NAPGCM), a voluntary organization with newly 1,600 members.  To qualify, the association says applicants must be licensed in their fields and train in geriatric, and they must adhere to professional guidelines and ethics.

NAPGCM has developed grievances procedures and will dismiss members who violate its requirements. (See box on hiring a care manager.)

THE ABCs OF MANAGING CARE

The first thing Pearlbea LaBier, a geriatric care manager in Bethesda, Md., who's the head of membership for NPGCM, does for a new client is assess the older person's life—physical and mental health, family relationships, living conditions, finances and legal affairs.

She then draws up a "plan of care" based on her evaluation.  Like her colleagues, LaBier says one of her most crucial tasks—and one that professionals sometimes do better than family members—is to convince the person to accept advice and help.

Competent care managers are able to find and hire needed help—home care workers, lawyers, nurses or even someone to mow the lawn.  Many straighten out finances and kitchens.  They may persuade clients that it's no longer safe for them to drive.

Erica Karp says that if a hard decision must be made—a move to a nursing home or hospitalization, for example—it may be easier for the care manager than a family member to be the "bad guy."

In some cases, the role of care managers is narrower.  They simply evaluate the older person's needs and draw up a plan for the immediate future.  If the situation changes, they may do subsequent "tuneups."

Not all geriatric care managers are created equal.  Some may lack the necessary training or experience. Some may give poor advice.

A Silver Spring, Md., man discovered this to his dismay a few years ago.  After his 94-year-old mother suffered a heart attack, he wondered what type of future living arrangement would be in her best interest:  living alone in her Santa Ana, Calif., apartment?  A nursing home?  Or some other facility?

He hired a geriatric care manager suggested by a friend to evaluate his mother and make a recommendation.

By the time he arrived in California 10 days later the care manager was waiting with her appraisal, which she said was based on a day of visiting the older woman and watching her in a rehab unit of an Orange County nursing home.

She concluded his mother could not live safely outside a nursing home.  She charged $300 for this advice and offered to stay on the case.

Unconvinced by this assessment, the son hired a professional nurse and enlisted the support of the Orange County ombudsman program.  A new evaluation came up with a different conclusion.  His mother had the physical and mental prowess to live a quasi-independent life.

The man fired the geriatric care manager and moved his mother to an assisted living facility, where she lived successfully for several years.

WHAT'S THE COST OF CARE?

One potential downside of care management is the cost.  Geriatric care managers charge between $80 and $150 an hour, so over time the costs can add up significantly.

Long-term care insurance policies often cover the costs of a geriatric care manager, but Medicare does not.

Despite the price Jan Collins, a South Carolina attorney who specializes in elder law, frequently recommends geriatric care managers to his clients.  "Dealing with the elderly is a multidiscipline event," he says.

He points out that a care manager may actually save money by connecting families to useful community resources, including free ones, and steering them away from expensive living arrangements where fees may quickly rise without warning.  "[Families] who have the least," Collins says, "have the most to lose."

EARNING TRUST IS KEY

For a geriatric care manager, "the most important job is to develop trust in the relationship," says NAPGCM's LaBier.  As an example she cites a retired physician she cared for.

Accustomed to controlling every aspect of his life, the doctor had retreated at age 94 into a life of "sitting in his sunroom watching the grass grow," LaBier recalls.

He was also trying to care for his wife, who had dementia.  Bills piled up on the dining room table, no one made meals and their home was a mess.

Furthermore, LaBier says, "stockbrokers were churning him left and right," talking him into buying and selling stocks at an alarming clip.

The couple had outlived their children and had no relatives nearby, but a nephew in Germany discovered their situation and hired LaBier.

Suspicious at first of LaBier, the physician eventually allowed her to bring in help to clean up the kitchen and cook some meals.  She gradually persuaded him to deal with the bills and call the investment firm that was hounding the doctor to report the broker.  The doctor was able to fulfill his wish of staying in his own home until he died.

Unfortunately, it's usually a crisis—a broken bone, a hospitalization—that prods families to plan for elder care.  Care managers say they are having some success, however, in getting families to have a plan before a crisis develops.

The NAPGCM reports that even retirement-age people who are still healthy are arranging for their own eventual care needs so their younger relatives won't have to.

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'Can We Talk Price?'

Psst! That sonogram bill may be negotiable.  With costs rising, patients are starting to haggle—and surprisingly, some doctors are going along.  Daniel Costello on how to get 30% off your next exam.

John Reidelbach was pretty sore after some recent hospital surgery, thanks to a really huge bill.  But instead of just paying up, the Atlanta business consultant tried asking for a discount.

To his surprise, he got one.  "I said I'd pay part of it right then or all of it over the next few years," says Mr. Reidelbach, who got $950 knocked off the $1,900 bill.  "I guess they were in a hurry for the money."

In small but growing numbers, Americans are taking an innovative approach to controlling health-care costs:  They're haggling with their doctors.  Fed up with mounting health bills, consumers are getting as much as 30% off everything from eye exams to fertility procedures just by agreeing to pay upfront.  Others are holding their doctors over a barrel by waiting a few months to pay the bill.  Already, a new cottage industry of middlemen who negotiate health-care bills for patients report their haggling business is up as much as 20% in the last year.

Most of the new bargaining is being driven by health-care costs, of course, which even in this down economy are expected to rise more than 10% this year.  But employers are behind this, too.  Along with increasing insurance deductibles, many are introducing "lump sum" plans that cap how much a worker can spend on health care.  Add it all up, and there's more pressure on employees to bargain.  "Haggling with doctors may sound bizarre, but people can't afford to just keep paying more," says Arthur Levin, director of the Center for Medical Consumers in New York.  Plus, "When you know your doctor has a big house and a boat, what's the harm?"

Not that there aren't risks to trying to strike a deal.  While the American Medical Association says it believes doctors should be able to adjust their fees, experts worry that people too shy to haggle could get left out in the cold, or worse, pay higher rates down the road.  Others say negotiating with your doctor might upset the natural patient-physician rapport.  Another concern:  Patients, or even doctors, will shortchange care for a price break.  "It's bound to happen," says Dr. Vincent Riccardi, an internist in La Crescenta, Calif., who nonetheless has haggled with his patients.

Indeed, Marie Tzivas thinks she bought herself some bad bedside manner when she recently negotiated a deal with her fertility doctor.  After one unsuccessful $17,000 in-vitro treatment, the 39-year-old New York homemaker told her doctor she "wasn't Celine Dion" and couldn't afford to pay retail again.  He agreed to knock 20% off each of her next two procedures, but soon Mrs. Tzivas felt the doctor was rushing through appointments.  At times, "he was rude," she says.  Her doctor, Zev Rosenwaks, denies that:  "99.9% of my patients are happy, and I'm sorry she wasn't," he says, adding that he only offers discounts in special cases.

Gaining Momentum

Of course, people have been haggling for years over the costs of things insurance doesn't usually pay for, such as plastic surgery and psychotherapy. But only a tiny percentage of patients ever asked for price breaks.  They were even less likely to do so once HMOs and flat co-payments became so common in the early '90's.  Now, though, the practice is gaining new momentum, with patients negotiating either on the initial bill or on their out-of-pocket costs after insurance payments.  In fact, according to a recent Harris poll, 17% of consumers asked for a discount on a medical bill in the past year.

More importantly, almost half say they succeeded.  That's partly because there's more flexibility in medical costs than many people realized.  Most doctors, for example, still charge way more than Medicare's reimbursement.  While they argue that those fees don't come close to covering their costs, critics say the disparity is one sign of how much inflation is going on.  Case in point:  Many doctors charge about $100 for a general office exam, but Medicare only reimburses $25.

For Paul Easton, who is uninsured, paying retail to find out what was wrong with his back seemed absurd.  Because the procedure involved an MRI, a visit to the radiologist and a trip to his primary care doctor, the Baltimore resident aimed for a bulk discount.  He talked to all the doctors involved, insisted on an upfront total fee, agreed to pay before the procedure and got $600 knocked off a $1,050 bill.  "Goes to show that it never hurts to ask," says Mr. Easton.

While there aren't national statistics on how many doctors are willing to negotiate, experts say specialists seem to be doing it the most—because they tend to charge more in the first place.  What's more, even hospitals are starting to come up with their own policies on the matter.  In Columbus, Ga., for example, Hughston Sports Medicine Hospital now offers discounts on a case-by-case basis. Emory Peachtree Regional Hospital in Atlanta, meanwhile has seen enough new hagglers that it now accepts down payments in exchange for as much as 30% off the price of a bill.  "If we get a down payment that at least covers our costs, it's better than nothing," says Ken Matteauer, the hospital's comptroller.

To be sure, haggling is still hardly mainstream.  Some physicians won't even talk about the practice, fearing more patients will ask for deals.  Others feel the discounts will just cost them too much—especially given that their salaries have actually fallen in real terms over the past decade, giving them less room to negotiate.  Another concern?  That insurance companies will find out about the behind-the-scenes price-cutting and downgrade reimbursement fees for all patients.  "This is what they're all really worried about," says Randal Schultz, a Kansas City, Mo., health-care lawyer.

And then there's the whole issue of what sort of markdown to offer in the first place.  After all, unlike retailers, few health-care providers have experience this health-care system.  It doesn't make sense," says Megan McAndrew Cooper, editor of the Dartmouth Atlas of Hearth-care.

If anything, the lack of rhyme or reason in pricing creates a free-market atmosphere in which consumers feel empowered to bargain.  And the incentives are only expected to grow as more companies move toward "self directed" health-care plans where patients are given a lump sum of about $2,000 to $3,000 to spend as they want on medical costs.  While less than a million people are currently enrolled in such programs, one recent study says 30% of larger companies could begin offering them in the next five years.

Free-Market Financing

How far will haggling go?  While it's mostly grass-roots for now, the movement could gain momentum from a new source:  professional agents.  Dubbed health-care advocates, these outfits—often staffed with doctors-will wrestle deals out of other doctors.  Healthcare Advocates of Philadelphia, for one, charges up to $200 to help clients and says this business is up 25% in two years.  "It was the best $150 I have ever spent," says Stephanie Bichara, of Mt. Laurel, N.J., who hired the company after getting a pricey tab for dental surgery.

Of course, if none of those routes work, there's always the old-fashioned way of getting a good deal: Get angry.  Last summer, Jennifer Haugen had the quintessential bad doctor day—an hour wait and three botched needle pricks, followed by just three minutes with the doctor.  Furious, she complained to everyone from the office manager to her doctor—and came away with two free office visits.

"I never yelled," says the 22-year-old Everett, Wash., student.  "But I think they knew how mad I was."

How to Haggle

BRAVE ENOUGH to ask your doctor for a deal on your medical bills?  Maybe you should be.  Here are a few techniques patients say work best for getting a break on the bill.

1. Pay upfront. Like most of us, doctors and hospitals prefer not to wait.  Some places, like Emory Peachtree Regional Hospital, will even take down payments and arrange for a discounted payment schedule.  "It's better than nothing," says a spokesman.
2. Do your homework. How much does Medicare pays doctors for different medical procedures?  Find the amount and insist on not paying more.  One example:  A physical-therapy session, which normally runs about $175 an hour, gets about $75 from the government.
3. Get the "bundle" rate. For complicated procedures involving more than one doctor, ask to "bundle" services into one charge.  Paul Easton, of Baltimore, got a $600 discount on a $1,050 MRI after asking his primary doctor and radiologist to bundle their two faces and agreeing to pay cash.
4. Forgo your rights.  Some docs will take up to 10% off the tab if you agree not to challenge the bill.  "It could be risky, but it's easy." Says health-care consultant Elizabeth Woodcock.
5. Hire a negotiator. There are companies now that will haggle for you a small fee.  Pass along the bill to them, and they call the doctor to work out a deal on your behalf.  Companies like Care Counsel in San Rafael, Calif., and American Medical Consumers in La Crescenta, Calif., have seen as much as a 25% jump in their haggling business.
6. Pick your battles. Providers who do expensive, short procedures like Lasik eye surgery and even some orthopedic surgeries have a lot more wiggle room than those who spend several hours with one patient.  Another good bet: Teeth whitening.

Published in:  The Wall Street Journal. Friday, February 8, 2002.  p 1, 6.

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Paying Someone Else to Talk Back to Your Doctor

Article By: Milt Freudenheim

Published in: The New York Times, Sunday, January 6 2002. p 7.

More than six years ago, Nicholas Keane, a retired printer from Milwaukie, Ore., a Portland suburb, needed surgery for a back problem that was diagnosed as a severe case of spinal stenosis.  His daughter, Sheila Christensen, said he was told by the physicians in his Medicare H.M.O. that he "was too old for the surgery, even though he had be living independently and playing golf.  "They were just going to buy him a wheelchair," she said.

Angry and frustrated, she contacted Dr. Vincent Riccardi, an internist in La Crescenta, Calif., and an independent patient's advocate.  He helped Ms. Christensen persuade her father's doctors to proceed with the surgery, which turned out to be a success.  And Mr. Keane, now 89, has been walking ever since.  "He would not be here if it were not for Dr. Riccardi," Ms. Christensen said.

Dr. Riccardi, who started the nonprofit advocacy company, American Medical Consumers, in 1992, is one of a small group of independent personal advocates who help patients around the country resolve disputes with insurance companies and doctors over what treatments are medically necessary and who should pay for them.

They are not to be confused with the lawyers who specialize in health care cases or the patient advocates hired by hospitals.  Some personal advocates work directly with patients for a set fee or a percentage of the reimbursement amount, while others are hired by employers, typically charging them a small monthly fee of less than a dollar a month per employee.  Some do both.  The advocates include companies like Healthcare Advocates of Philadelphia, Managed Care Resolutions of Seattle and Care-Counsel of San Rafael, Calif.

The advocates' services certainly sound appealing - after all, who hasn't had problems with managed-care, especially as rising health care costs continue to affect many people's benefits?  Many doctors have given up their traditional role as advocates for their patients, Dr. Riccardi said, in come cases, "because of the nature of the contracts they have signed" with managed-care insurance companies and medical groups.  And some employers that provide health care benefits have been shying away from insurance disputes because of lack of time or staff.  As a result, more people are finding themselves personally haggling over their medical coverage.

But does everyone need to hire an advocate?  And does it really help?

There are plenty of free services that consumers should use first, health care experts say.  For many people, the first source is probably their employer's human resources or benefits department.  Some employers provide strong voices for their employees, intervening actively on their behalf with insures, but others may do little to help.

All managed-care companies, meanwhile, have procedures for appeals to an in-house reviewer, usually a doctor.  In most states, consumers can also appeal to an external review board.

If all that fails, patients can seek assistance from a state agency that regulates insurance companies.  There are also ombudsmen agencies for the Medicare and Medicaid programs in every state.  The Web site of the Connecticut Office of Managed Care Ombudsman (www.omc.state.ct.us), for instance, explains patients' rights under state law and provides step-by-step instructions for filing complaints.  Health Care experts say such agencies' effectiveness, however, varies form state to state.

Consumers who still want outside help can read about the advocates' credentials and goals on the Web sites.  Most advocates say they accept clients only if they have a strong chance of having their medical needs met.  And Dr. Riccardi says he often advises prospective clients about ways to pursue their own cases.

If the H.M.O. says no, you might get help from an expert.

Many personal advocate services have sprung up over the last decade, often by people who have had their own share problems with managed health care.  One of them was Robert Clydesdale of Newburgh, N.Y., who became infected with Lyme disease in 1987.  Mr. Clydesdale said he was unaware of his illness for eight years, but by the time he began receiving treatment for it, his condition had deteriorated to the point where he was blind in one eye and needed a walker to get around.  Mr. Clydesdale ran up substantial medical bills, which, he said, his insurer initially balked at paying in full.  He found Patients America in Garden City, N.Y., about two years ago.

Kevin Flynn founded Healthcare Advocates (www.healthcareadvocates.com) in Philadelphia in 1996 after years of having difficulty getting care for brain injuries he suffered when he was struck by a car 10 years earlier while a computer science student at the University of Pennsylvania.

"They said I would be a vegetable," he recalled.  "My insurance ran out.  Then I was on Medicaid.  A neurologist kicked me out of his office.  No one should get kicked out of a doctor's office because the doctor is not going to make much money on a case."

Mr. Flynn said he started his business with "a large nest egg" that he had accumulated while working on oil exploration projects with geophysicists in the early 1990's.  He says that, on average, 85 percent of the cases he handles are considered a success, which could mean anything from getting treatment for a client to having a bill paid by an insurer.

One of Mr. Flynn's longstanding clients is Christina Seguine, now 26 and legally classified as disabled.  She was an active soccer player as a teenager, but dropped out of college because she had depression, trouble concentrating, joint pain and heart problems, according to her mother, Linda Seguine of Woodbridge, N.J., a clerk-typist employed by Middlesex County.  She eventually used up the lifetime limit of $50,000 on outpatient mental health coverage in the Middlesex County Joint Health Insurance Fund.  Eventually, late-stage Lyme disease, with complications, was diagnosed, her mother said, adding that Lyme disease was the likely source of all her problems.

Mr. Flynn helped the Seguine family persuade the county health insurance fund that she should receive additional coverage, beyond the mental health ceiling, for her physical symptoms.  Under that agreement, the insurance company has already picked up $25,000 of the costs, with more to come, Mr. Flynn said.

His fee was "$99 total," Mrs. Seguine said.  There was an additional $200 retainer fee for a lawyer who handled the appeal.

Dr. Riccardi says his initial fee is usually $50.  For that, he says, he reviews a patient's records and may call a hospital administrator or doctor to tell them of his client's concerns.  But in uncomplicated cases, he says, he often explains the system to patients or family members who then become their own advocates.  California residents are encouraged to seek help from the state's recently established Department of Managed Health Care.

"I give them the moxie - I say, 'do it yourself.'  I let them know it's O.K. not to be deferential," he said.

Ms. Christensen, whose father had the spinal surgery, says the advice she received from Dr. Riccardi not only saved her family money but also helped her father receive the medical care he needed.

After surgery, he was transferred to a nursing home for rehabilitation.  When the nursing home tried to discharge him in less than a week, while he was still unable to move, Ms. Christensen said, she contracted Dr. Riccardi again and received useful tips that helped extend his care there to 16 days.

By the time he was discharged, he did not need a wheelchair, she said.  Now at an assisted-living center, "he is living on his own, a burden to no one," she added.

When a health plan declines to approve care, Dr. Riccardi advises patients to contact their doctor to make sure that he or she uses the correct language in a health plan contract.

Managed Care Resolutions, a new company headed by Wolfgang Klamp, a health care management consultant in Seattle, charges, on average, $49.95 for an individual claim.  It also provides services through employers, charging 75 cents a month per employee; small companies with fewer than 250 employees pay a total of $200 monthly.

For more difficult cases, including denials of coverage of experimental medicine, the charge is $195 to review the case and to come up with a plan of action.  Then the charge is $100 an hour.  Other cases are taken on a contingency basis, for a fraction of any insurance payments obtained.  He said his company had had several hundred inquiries since it started four months ago.

"People really need the help," Mr. Klamp said, noting that in 1999 alone, 22,000 people complained to the New York State insurance department about denials of health care claims.  "People go bankrupt for this.  They don't know where to turn."

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