Understood Care (04/22/25)

Written by Debbie Hall - Director of Operations at Understood Care | 20+ years of experience in CDPAP program management and home care coordination | Updated February 2026

A Medicare patient advocate is someone who works on your side to coordinate medical care, fight billing errors, file insurance appeals, and make sure you actually get the benefits you're paying for. Most Medicare patients pay $0 out of pocket for advocacy services, and the difference between having one and not having one can be thousands of dollars in avoided costs and months of avoided frustration.

Key Takeaways

A patient advocate coordinates your care, fights billing errors, and files insurance appeals so you do not have to navigate the system alone.
Medicare funds free advocacy through SHIP counselors in every state - most patients never need to pay out of pocket.
Appeals filed with advocate help succeed roughly 80% of the time, compared to just 11% of patients who attempt appeals on their own, per CMS appeals data.
Four types of advocates exist: hospital-employed, independent private, nonprofit (SHIP/SMP), and Medicare Beneficiary Ombudsman - each with different costs and scope.
You do not need a referral to work with a patient advocate. You can contact one at any time.

This article is part of our Complete Guide to Medicare and CDPAP in New York - a comprehensive resource covering Medicare benefits, CDPAP eligibility, caregiver pay rates, appeals, and patient advocacy.

Quick Answer

A Medicare patient advocate coordinates your care across doctors, reviews and disputes medical bills, files insurance appeals, manages medications, and navigates Medicare rules on your behalf. Most Medicare patients pay $0 out of pocket for advocacy services through hospital programs, nonprofits, or SHIP counselors.

If you've ever stared at a medical bill that made no sense, spent 45 minutes on hold with Medicare, or felt like your doctors weren't talking to each other, you already understand the problem. The healthcare system wasn't built for patients. It was built for billing departments. A patient advocate exists to tip the scales back in your favor.

Quick Summary

A patient advocate helps you navigate the healthcare system - billing, appeals, insurance, and care coordination.
Free options: SHIP counselors (call 1-877-839-2675), hospital patient representatives, nonprofit advocacy groups.
Paid options: Private advocates cost $100 to $200 per hour.
Medicare does not pay for private advocates, but SHIP counseling is always free.
A family member can also serve as your advocate at no cost.

What Does a Patient Advocate Do Day to Day?

The word "advocate" gets thrown around a lot in healthcare, so let's get specific. A Medicare patient advocate handles the work that falls between the cracks of your medical care. That means everything your doctor doesn't have time for and everything your insurance company hopes you won't figure out.

Here's what that looks like in practice:

Coordinating between your doctors and specialists. If you see a cardiologist, a primary care physician, and an endocrinologist, your advocate makes sure they're all working from the same page. That means sharing test results, flagging medication conflicts, and making sure nobody orders duplicate labs.
Reviewing and disputing medical bills. Medical billing errors affect roughly 8 out of 10 hospital bills, according to the Patient Advocate Foundation. Your advocate reads every line item, catches duplicate charges, flags services you never received, and negotiates with billing departments on your behalf.
Filing insurance appeals. When Medicare or a Medicare Advantage plan denies a claim, most people just accept it. An advocate knows exactly how to write an appeal letter, what documentation to include, and which deadlines matter.
Managing medications. Your advocate can review your full medication list, check for dangerous interactions, and help you find lower-cost alternatives when your prescriptions get expensive.
Preparing you for appointments. That means helping you write down your questions beforehand, reviewing your medical records, and sometimes joining your appointments virtually to make sure nothing gets missed.
Navigating Medicare rules. Original Medicare, Medicare Advantage, Medigap, Part D, SNPs - the system has more moving parts than most people realize. Your advocate knows which plan covers what and when you're eligible to switch.

When Do You Actually Need a Patient Advocate?

Not everyone needs an advocate all the time. But there are specific situations where having one can save you real money and real stress.

You should consider getting a patient advocate if:

You were recently diagnosed with a chronic condition like diabetes, heart disease, or COPD
You're managing care across three or more doctors
You received a medical bill over $500 that you don't fully understand
Medicare denied a claim or prior authorization
You're transitioning from a hospital stay to home care (including programs like CDPAP)
You're a caregiver for an aging parent and can't keep up with the paperwork
You feel like your concerns aren't being heard during appointments

Here's the thing - most people don't look for an advocate until they're already in crisis. A surprise bill shows up, a treatment gets denied, or a loved one is discharged from the hospital with no clear plan. Getting an advocate before the crisis hits gives you a much stronger starting position.

How Do You Get a Patient Advocate Through Medicare?

Medicare itself doesn't assign you a personal advocate, but there are several ways to access advocacy services at no cost.

State Health Insurance Assistance Programs (SHIP). Every state has a free SHIP program funded by the federal government. SHIP counselors help with Medicare questions, plan comparisons, and billing disputes. Visit shiphelp.org or call 1-877-839-2675 to find your local office.
Medicare Advantage plan care coordinators. If you're enrolled in a Medicare Advantage plan, your plan may include a care coordinator or case manager. Call the member services number on your insurance card and ask specifically for care coordination.
Hospital patient advocates. Most hospitals with more than 100 beds have a patient advocate or ombudsman on staff. Ask at the front desk or call the main hospital line.
Virtual patient advocacy services. Companies like Understood Care provide remote advocacy that covers care coordination, bill review, and insurance navigation. Virtual services work nationwide and don't require you to travel anywhere.
Your doctor's office. Some primary care practices now employ care navigators or social workers who can help coordinate your care. Ask your doctor if this service is available.

Types of Patient Advocates: A Comparison

Not all patient advocates do the same work. The type you need depends on your situation, your budget, and how complex your Medicare issue is.

Type	Cost	Best For	How to Access
Hospital Patient Advocate	Free (employed by hospital)	Billing disputes, discharge planning, care coordination during a hospital stay	Ask the front desk or nursing station at any hospital
SHIP Counselor	Free (government-funded)	Medicare enrollment questions, plan comparisons, benefits counseling, simple appeals	Call 1-800-MEDICARE or visit shiphelp.org to find your state program
Medicare Beneficiary Ombudsman	Free (CMS-appointed)	Systemic Medicare complaints, access-to-care issues, managed care grievances	Contact the Medicare Beneficiary Ombudsman at cms.gov
Independent Private Advocate	$100 - $250/hour	Complex cases: multiple denials, chronic illness coordination, large medical bills, legal-adjacent issues	Search the Patient Advocate Foundation or AdvoConnection directory

Most Medicare beneficiaries start with a SHIP counselor. If your case involves multiple denied claims, coordination across several providers, or bills exceeding $10,000, consider an independent advocate.

Free Medicare Help

Call 1-877-839-2675 to reach the national SHIP helpline. SHIP counselors are free, trained by Medicare, and available in every state. They can help with billing, appeals, and choosing the right plan.

What Does a Patient Advocate Cost?

The cost of a patient advocate ranges from completely free to several hundred dollars per hour, depending on the type you choose and the complexity of your case.

Service	Typical Cost	What Is Included
SHIP Counseling	Free	Medicare enrollment help, plan comparisons, benefits questions, simple claims issues
Hospital Advocate	Free	Inpatient billing disputes, discharge planning, care coordination within the hospital system
Nonprofit Advocacy (Patient Advocate Foundation)	Free	Insurance appeals, prior authorizations, copay assistance, case management for specific conditions
Independent Advocate - Hourly	$100 - $250/hr	Complex appeals, multi-provider coordination, large medical bill negotiation
Independent Advocate - Flat Fee	$500 - $3,000/case	End-to-end appeal management, insurance negotiation, full case resolution
Virtual Advocacy Platforms (Solace, Health Advocate)	$0 - $150/session	On-demand support, telehealth coordination, benefits navigation

According to the Patient Advocate Foundation, over 80% of Medicare patients who need advocacy can get it at no cost through SHIP, hospital programs, or nonprofit organizations. Private advocates are typically only necessary for cases involving denied claims over $10,000 or multi-year billing disputes.

What's the Difference Between a Patient Advocate and a Case Manager?

These roles overlap, but they're not identical. A case manager typically works for your insurance company or hospital. Their job is to manage your care within the system's rules and budget. A patient advocate works for you. Their loyalty is to your health outcomes and your wallet, not to the institution.

That distinction matters most during disputes. If your Medicare Advantage plan denies a prior authorization for a knee replacement, your plan's case manager represents the plan. Your advocate represents you.

Can a Patient Advocate Help with Medicare Appeals?

Yes, and this is one of the highest-value things an advocate does. Medicare has a five-level appeals process, and most patients give up after the first denial. An experienced advocate knows that roughly half of all Medicare appeals are decided in the patient's favor when they're properly filed.

The appeals process works like this:

Redetermination - your Medicare contractor reviews the claim again (60-day deadline to file)
Reconsideration - a Qualified Independent Contractor takes a fresh look (180-day deadline)
Administrative Law Judge hearing - for claims over $190
Medicare Appeals Council review
Federal court - for claims over $1,900

Your advocate handles the paperwork, gathers supporting documentation from your doctors, writes the appeal letter, and tracks every deadline. You don't have to become an expert in Medicare regulations. That's literally what they're for.

How to Choose the Right Patient Advocate

Not all advocates have the same training or focus areas. When you're evaluating your options, look for these specifics:

Medicare expertise. General patient advocates may not know Medicare's specific rules. Ask how many Medicare clients they currently work with.
Credentials. Look for Board Certified Patient Advocate (BCPA) certification or a background in nursing, social work, or healthcare administration.
Communication style. Your advocate should explain things in plain language and respond to messages within 24 hours. If they can't explain a concept clearly to you, they won't explain it clearly to your insurance company either.
HIPAA compliance. Any advocate accessing your medical records must follow HIPAA privacy rules. Ask about their data security practices.
Track record. Ask for specific examples of appeals they've won or billing errors they've caught. Vague answers are a red flag.

Interview Your Patient Advocate: 8 Questions to Ask

Before you commit to working with a patient advocate, ask these questions to make sure they are the right fit for your situation.

What experience do you have with Medicare specifically? - General healthcare advocacy is different from Medicare expertise. You want someone who knows CMS rules.
Have you handled cases like mine before? - An advocate who has won appeals for your specific type of denial is more valuable than a generalist.
What is your fee structure? - Hourly, flat rate, or contingency? Get this in writing before you start.
How will you communicate with me? - Phone, email, patient portal? How often? Set expectations upfront.
Will you attend appointments with me? - Some advocates join doctor visits or hospital meetings. Others work behind the scenes.
What documents do you need from me? - A good advocate will give you a checklist: Medicare Summary Notices, Explanation of Benefits, medical records, prior authorization letters.
What is your success rate with appeals? - Ask for specifics. How many appeals have they filed? How many were overturned?
Do you have references from other Medicare patients? - Testimonials from people with similar cases are the strongest signal of competence.

Tip: Print this list and bring it to your first meeting. A good advocate will welcome these questions. If they get defensive, keep looking.

Watch: The Role of the Patient Advocate

This video from Riverside Health explains the daily role of a patient advocate, including how they help with billing disputes, care coordination, and communication between patients and medical teams.

Your Next Step

Not sure if you need an advocate? Start with a free SHIP counselor. Call 1-877-839-2675 and describe your situation. They will either help you directly or point you to the right type of advocate.

Key Takeaway

Most Medicare patients can get advocacy help at no cost through SHIP. If you need more specialized help - like for a complex appeal or billing dispute - private patient advocates typically charge $100 to $200 per hour.

Frequently Asked Questions

Does Medicare pay for a patient advocate?

Medicare does not directly pay for a standalone patient advocate. However, Medicare funds free SHIP counselors in every state, and many Medicare Advantage plans include care coordination at no extra cost. Virtual advocacy services may also be covered depending on your plan.

What is the difference between a patient advocate and a patient navigator?

A patient navigator typically helps you move through a specific diagnosis or treatment path, like cancer care. A patient advocate covers a broader range of services including billing disputes, insurance appeals, medication management, and ongoing care coordination across all your conditions.

Can a family member be a patient advocate?

Yes. A family member can advocate on your behalf, especially with a signed healthcare proxy or power of attorney. However, professional advocates bring specialized knowledge of Medicare rules, billing codes, and appeal procedures that family members usually don't have.

How do I file a complaint about my Medicare coverage?

You can file a grievance directly with your Medicare plan by calling the member services number on your card. For broader complaints about the plan itself, contact 1-800-MEDICARE (1-800-633-4227). A patient advocate can file these complaints on your behalf and follow up to make sure they're resolved.

Is patient advocacy available in all 50 states?

Yes. SHIP programs operate in all 50 states plus the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. Virtual advocacy services like Understood Care also work nationwide since everything is handled by phone and secure online communication.

Key Takeaways

Patient advocates coordinate care, fight billing errors, file appeals, and navigate Medicare rules.
Most Medicare patients pay $0 - look into hospital advocates, nonprofit programs, and SHIP counselors first.
Consider getting an advocate when managing 3+ doctors, facing a denial, or dealing with a new chronic diagnosis.
An advocate is different from a case manager - advocates work for you, case managers work for the insurer.

The Complete Guide to Medicare and CDPAP in New York for 2026 - Our comprehensive guide covering everything in one place
Medicare Part A vs Part B - What Each Covers - Side-by-side comparison of hospital insurance vs medical insurance, with 2026 costs
What Is CDPAP and Who Qualifies in New York? - Eligibility requirements, income limits, application process, and what services CDPAP covers
How Much Does CDPAP Pay Caregivers in New York (2026)? - 2026 pay rates by region, overtime rules, and how CDPAP compares to agency work
How to Appeal a Medicare Denial Step by Step - The 5-level appeal process, deadlines, and tips to strengthen your case

Written by

Debbie Hall

Director of Operations at Understood Care. 20+ years of experience in CDPAP program management and home care coordination across New York.