“Helping Patients Find & Understand Healthcare Benefits” with Anne McGuire of Healthcare Pathfinder

Jonathan (0s):
Welcome back to radio entrepreneurs. I’m Jonathan Freedman on the next guest is Anne McGuire, president donor of Healthcare Pathfinder. Welcome to Radio Entrepreneurs.

Anne (9s):
Well thank you for having me.

Jonathan (11s):
So you were operating in one of these spaces that is, is just so valuable and so incredibly important for people. Tell us a little bit about what it is that your company does and, and, and how you’re helping people out.

Anne (24s):
So we are a healthcare advisers advocates and insurance managers. So we help with healthcare and long-term care. And we really have been providing these services in various capacities for the past 20 plus years, and I’m a nurse and a certified case manager. So that’s where it all comes from, is the wanting to help people out.

Jonathan (51s):
So you really early in your career understood it from the other end of the spectrum, but you know, perhaps a whole other perspective when you’re working with your clients today and, and helping them navigate through, you know, some very difficult issues, probably dealing with, you know, in, from populations, whether it’s due to aging or due to, to health. And the last thing people need is, is complexity associated with navigating insurance and restrictions that are often imposed B because we know that insurance companies, if they deny services tend to make more money, but that’s not their sole purpose, but it’s a very difficult and constantly changing landscape.

Jonathan (1m 37s):
So how is the average consumer supposed to navigate their way through this? That’s where you come?

Anne (1m 42s):
Yeah, that’s all right. Come in and just help, you know, and what I say, we help people find, understand and advocate for their health insurance benefits. So we, a lot of clients, we do our consultants where they come to us and we help them choose their coverage and help them understand what their benefits are instead of just going to buy a policy based on the price and people who are going through transition. So that’s sort of the area where we really can help people understand and, and have an impact on their own health care costs is by going through that process and reviewing their coverage.

Anne (2m 24s):
So a lot of people who are going through transitions, that’s where we get involved in helping them find their insurance coverage. We don’t sell insurance. I am licensed in life and health, but we don’t sell and then helping them understand and how to, you know, log on to the insurance company websites. When you make a call to the insurance company, write down who you spoke to all of these sort of just helping them sort of manage it, if you will.

Jonathan (2m 52s):
And it’s become a much more complex environment. You know, I know just in a simplified manner, as, as the responsible for benefits administration in our firm, you know, the landscape has shifted over the last call. It three to five years, you know, certainly over the last decade where it’s very hard to compare apples to apples. And it’s very hard to look at things and say, this is what your costs are because a lot of the burden has shifted towards consumers over the last, as I say, three to five years, I, I certainly notice it in my own pocket book. And I’m sure most people do in their wallets as well. You know, the, the zero to dunk gone are the days of the $0 copay and, and very small copay deductibles today.

Jonathan (3m 35s):
People are probably foregoing medical services just because of the cost of, of going to do something. And that’s not a good thing. So tell us what you’re seeing and, and, and how that’s impacted your business and what you do for people.

Anne (3m 50s):
Well, it actually goes back to probably about 25 years ago when I was a visiting nurse. So I actually started in intensive care at Yale new Haven, and then really didn’t like the hospital. So I went into home care and after eight years insurance companies, this was in the sort of early nineties insurance companies started calling up and approving an authorizing the amount of visits and how often we can see our patients. And so that’s where I said, oh no, you know, we had to submit all these documents versus under most of the Medicare benefits, we really did what we needed to do and then stopped providing services when someone was stable and, you know, we had guidelines and then we moved and I ended up going to Massachusetts and working for a managed Medicare insurance company.

Anne (4m 48s):
And that’s where I sort of really

Jonathan (4m 52s):
There side of the other, other side of the coin in terms of how things work.

Anne (4m 55s):
I said, I’m going to the other side and I’m going to help out other people. And so that’s where I really learned. And it was really a great experience of working with medical providers. I was working for the insurance company, but I worked for medical providers and I followed the clients, the patients through the continuum of care from prehospital through hospital to discharge, planning to home. And that’s where I followed. And we track not only the care, but it was really looking, it was a capitated environment where the physicians were being paid per member per month. So it was up to them to determine what they wanted to pay for and what they didn’t. So that was really interesting.

Anne (5m 36s):
And then we moved again and that’s where I joined a firm that was really on the advocacy side. And initially, so go ahead.

Jonathan (5m 46s):
We’re getting into the politics of it all, because I know it’s such a charged issue in this environment and full disclosure, I’m Canadian. So I understand socialized medicine, as a, as I told you, before we came on, I come from a line of doctors and it just put an unfair burden on the providers in this country to be able to say to them, instead of saying, what’s in the best interest of the patient, they’re trying to manage, you know, so many other variables. And now when I understand, you know, unlimited cost is not a good thing, but being able to really provide what they deem the best care possible for their patients. And whether we’re talking about physicians or nurses or nurse practitioners, these are people who are very well educated and experienced in patient care, and shouldn’t, they be able to, to make a determination without fighting the battle.

Jonathan (6m 30s):
I’ve heard, you know, again, anecdotal stories, many doctors who have left the profession and are saying, I’m fed up, I’m fed up doing battle with insurance companies over what I feel is the best course of treatment for my patient. So tell us about that. And I, you know, again, I try not make it politically charged, but you know, how do you help your clients to navigate that world and, and frustrated physicians, et cetera. So, and, and have you seen this from your perspective being on the managed care side as well,

Anne (6m 56s):
Right. And it’s, you know, and it was COVID, you know, it’s just, what we’ve all gone through this past year is really makes you want to think that, oh, it’s going to all shift, you know, the, where money is going to, they’re going to pay nurses and care providers more. And so it’s, it’s, it’s such a unfortunate situation and it really is so much about the money. And that’s, I find where my background can be so impactful from the advocacy side is because I understand the insurance side and I know what’s driving the care. And if you can really think about, you know, that’s where the battle does come in, and that’s where the physicians do get fed up.

Anne (7m 43s):
And that’s where I try to help out to be proactive and also support the physicians, especially when it comes to the appeals, et cetera. But the communication, I think, unfortunately, patients just sort of sometimes listen to what the doctors, whatever say, and they need to say, but wait a minute, you know, I’m not feeling good. Or, you know, it’s sort of really the communication side, but on the insurance side, it is they’re checking boxes off and it’s criteria and people are being put in boxes and it, you need to be thinking outside of the box, you know, really, as far as

Jonathan (8m 24s):
We’re, we’re, we’re all, we’re, we’re all taught to be, we’re all individuals and, and, and each individual has individualized needs. And I think, you know, healthcare and, and putting it in a box and treating everybody the same just doesn’t work. You know, I’ve heard from, from physician friends over the years, you know, things are said to the lay person. It seems like when you treat a cancer, you treat again, no, they’re all different. You know, there are many different types and may different. They react differently in different people. And so you can’t have a one size fits all approach,

Anne (8m 53s):
But our system is not very efficient. I still am amazed that our system is still five days a week. Basically, you know, it’s not 24 seven, you know, it doesn’t even have to be 24 seven, but at least be seven days a week. You know, when you go into the hospital on Friday and you still can’t get tests done until Monday, things of that sort. And, you know, just there is just, there’s a lot of problems where the system doesn’t move forward because, and this goes back, I was just doing my licensing. I have to do continuing ed. And it was really, physicians have always been worried about insurance companies from the beginning, because they were concerned about what it was going to do to the amount of money that they made.

Anne (9m 38s):
And so that’s been from the beginning, but it’s just, it’s protected individuals as well as by having that insurance so that there is, you know, they get help with the risk. So

Jonathan (9m 53s):
You talked a little bit about where you often come in is where people are going through transitions and helping them navigate insurance coverages. What other types of services are you providing? And, and when I give you an opportunity to talk about some scenarios or, or some examples of them and, and where you can, can help out consumers, particularly are the ones that engage with you, correct?

Anne (10m 15s):
Oh yeah, exactly. So, and you know, I’ve been working with a lot of financial advisors who really, now that long-term care has really become sort of an awareness of how people have been going bankrupt. I think that’s become an area where financial advisors say, okay, you know, we need to make sure our clients have the right insurance. So that’s an area where we do that transitions with, you know, people who are going through a divorce or retiring. And I just really understanding what their options are. And then the other areas with clients who have significant diagnoses and, you know, going through talking to these people who get the new diagnosis, who go all over the country, just wanting to try to find a cure, writing checks to doctors and providers all over the place, not even worried thinking about the insurance, they figure they’ll deal with that later, instead of being proactive and really helping them and say, just send me everything.

Anne (11m 16s):
So we can talk to your providers. We can get that prescription that you’re getting at that private doctor’s office. We can get it covered under your Cigna insurance and not necessarily is it always easy, but when it’s $5,000 a month and you’re get, you get the full coverage, you know, it’s great. So there’s those types of services. And then the, and then long-term care claims where the children have their parents who get sick. And then they have, if they’re lucky they have a long-term care insurance. So from the insurance side, we help with initiating claims and how to do that. And then there’s the healthcare advocacy side where I have two clients right now, actually three, two are on the younger side, we’re in car accidents and it’s, it’s helping the family understand the insurance side, but also helping them speak the language, ask the questions, what to ask for w you know, why aren’t you providing these services and then dealing with the insurance company saying, oh, sorry, you’re done.

Anne (12m 25s):
It’s time for you to go home. We’re not paying for this anymore and helping deal with that appeal, but hoping to avoid it by advocating in advance,

Jonathan (12m 36s):
Really a whole breadth of services and really important stuff. And how does your model typically work? Is it a fee for service model? Is there any upside, you know, I imagine in certain cases, and you’d probably just cite it a couple of examples where you’ve saved people thousands, if not tens of thousands of dollars, is there, is there some, some sharing of that when our, is it strict the fee for service for the time that you invest in the, in the, in the case?

Anne (13m 2s):
Right. I, I, it’s so hard to project how long things are going to take. So it’s really, as far as sharing in the wind is a, you know, a lot of it sometimes it’s, you don’t see it because there is the savings that takes place. You know, that just by being proactive, you saved money. But we do have the clients who, you know, often it’s the out of network they’ve been skiing and got in an accident, and they’ve got, they’re submitting these claims to the insurance company. They’re in the state, the insurance company only pays a certain amount, and then they get all these other bills, balance bills, and it’s negotiating on those sometimes winning the appeals. I mean, I don’t take an appeal on, unless I really know it’s, it’s worth taking on and so very successful with, with appeals.

Anne (13m 53s):
And so that does save people a lot of money, but from the fee for service side, it’s, it is sort of an hourly, but I do have clients who are retainer or sort of ongoing clients where we have authorizations on file with the insurance company and can speak to the insurance company on their behalf with any issues that come up related to their health insurance. So it’s really an ongoing management availability to be there if they have any issues. And that’s a lot of people who have are older or they’re chilled, the children want to have their information with us so that we can, they can call us so we can jump in at any time.

Jonathan (14m 35s):
Great, great stuff. And, and we can, this is an area that I’m passionate about. We can probably spend hours discussing. And if people want to get in touch with you like to learn more about what it is that you do and how you can help them, what’s the best way for them to reach you.

Anne (14m 49s):
They can email me at an or a Maguire. So a M C G U I R E a maguire@healthcarepathfinder.com, or they can call me at (203) 656-2167

2 (15m 5s):
Great stuff. And it’s been a pleasure getting to know your, learn more about your service Anne McGuire, president, owner of healthcare, Pathfinder, LLC. It’s been a pleasure having you on radio entrepreneurs.

Anne (15m 16s):
Thank you very much. I’ve enjoyed it. And I’ll look forward to talking to you more about it.

2 (15m 21s):
Absolutely. We’ll be right back with another segment on radio entrepreneurs.