1 JAN. 22, 1898.] MEMORANDA. LMIMIrAN 2II his leaving hospital he was attacked by epileptiform convulsions. On February zith, i896, while at work his ...
a p u b l i c at i o n o f
Laughing, Smiling and Surviving After a life-changing diagnosis, Marilyn Kramer still manages to stay positive and face each day as it comes.
very so often you meet a person who changes the way you think. Something about their story, perspective or personality challenges your previous views. It’s pretty rare and it takes a very special individual—someone like Network Health Medicare Advantage PPO member, Marilyn Kramer. Marilyn’s sweet disposition is apparent from the moment you meet her. A warm smile spreads across her kind face and it’s difficult to imagine all of the intense challenges she’s faced over the years. From struggling with lupus as a child, to her battle with breast and thyroid cancer, Marilyn doesn’t
allow her health conditions to get her down—or at least not for long. She makes it perfectly clear from the start. “How I deal with things may not be how someone else deals with things,” says Marilyn. She understands that her outlook is pretty unique and it may not be for everyone. But, she committed herself to laughing, smiling and staying positive even when facing life-threatening conditions. That’s quite the achievement considering most of us can’t even stay positive after getting a parking ticket or spilling coffee on ourselves. Two and a half years ago, Marilyn scheduled a mammogram
“I’ve been given access to the best health care the Fox River Valley has to offer, and I have met some of the most amazing people one could hope to meet.” H5215_MbrNewsv3 Accepted 110712
Marilyn with her health care team from Dr. Burkett’s office - Laura Baehnman, Shelly Dibelius, Jenny Jaehnke, Mary Ellen Buechel, Linda Borsecnik. after feeling that something just wasn’t right. Nearly all of the women in Marilyn’s family had been diagnosed with breast cancer at some point in their life, making Marilyn very attentive to any changes in her health. After feeling a dull pain in her breast a few nights in a row, she made sure to
call her doctor right away. While it was tough to learn she had breast cancer, she did feel fortunate that she caught it at an early stage. The way she saw it, at least she knew what she was up against. She considered her family history and told her surgeon she’d prefer a continued on page 2 »
Volume 1 | Number 3 | 2012
life, health & wellness
life continued from page 1 »
I had a choice.
“But, What was happening wasn’t going to change. The only thing I could control was how I decided to handle it.”
mastectomy instead of the recommended lumpectomy. Her surgeon didn’t agree the mastectomy was necessary, and Marilyn consented to the lumpectomy instead. After the lumpectomy, the cancer came back. This time it had spread into Marilyn’s lymph nodes. Six days after being told about the breast cancer reoccurrence, she was informed she had thyroid cancer as well. Going through a situation like that could probably make just about anyone resentful or bitter, but Marilyn refused to fall into self-pity. “I wasn’t always upbeat,” she says. “But, I had a choice. What was happening wasn’t going to change. The only thing I could control was how I decided to handle it.” Marilyn found a new surgeon. She was grateful that her Network Health Medicare Advantage plan gave her access to the area’s top doctors and specialists. She did her research and found Dr. Burkett of Neenah. After meeting with him and discussing her treatment plan, she felt much more prepared for the battle ahead. With the love and support of great friends and her sister Trudy, Marilyn bravely faced the surgeries and chemotherapy treatments. It was painful and exhausting, but through it all, Marilyn somehow managed to keep her playful sense of humor. When doctors asked what she preferred to be called, she’d reply “your highness.” And she once teased a new chemotherapy patient by telling him not to worry, his nurse (who was about to give him an injection) didn’t shake nearly as much since she’d been through rehab. WHAT’S That?
Marilyn’s oncologist, Dr. Goggins, was glad to see her keeping her spirits up. He informed her that patients with a positive outlook often experience more effective treatments. And, research supports this. According to a Boston University study, seniors with a positive attitude recover better from surgeries than those with a negative outlook. Of course, staying positive when facing powerful chemotherapy treatments isn’t an easy task, especially when the side effects result in painful and dangerous complications. In addition to experiencing the fatigue, nausea and hair loss commonly associated with chemo, in September of 2011, Marilyn almost died from her body’s reaction to the chemotherapy. All treatments had to be stopped until she could recover. Marilyn fought on. Though she continued to be challenged with multiple occurrences of bronchitis, pneumonia, shingles and radiation burns, she somehow stayed optimistic. She often told herself, “The day will be good no matter what.” She explains part of the reason for this optimism was she felt fortunate to have the best health care possible and a great team of people— including her health care concierge, Craig Kandler, to help her during her treatments and recovery. Marilyn believes this attitude can be attributed to her practical point of view. “Life is not a guarantee.” She refuses to waste time thinking about what could happen. Instead, she chooses to “enjoy good company and laugh as much as possible.”
Lumpectomy The most common form of breast cancer treatment today. It is the surgical removal of a lump.
Mastectomy The partial or complete surgical removal of a breast. 2 | C oncierge
Beat Holiday Blues
o you start to feel a little down or stressed around the holidays? If so, you’re not alone. Many adults feel a little blue this time of year. There are several reasons for this—the weather starts getting colder and grayer, the days get shorter and sometimes the festivities can bring back memories of loved ones we’ve lost. Don’t feel ashamed or embarrassed if you feel a little isolated from all the holiday cheer. It’s common to experience stress around the holidays. Some don’t even realize they’re struggling with a health concern, but the holiday blues can disrupt several different aspects of your life. You may experience restlessness, fatigue, a change in sleeping habits or a lack of interest in activities you previously enjoyed. The good news is there are effective ways to deal with holiday blues and enjoy the season. The tips below should help. Enjoy the Moment. Perhaps the greatest factor in enjoying the holidays is changing your perspective. It is natural to think back to “the good old days” and reflect on memories of past Thanksgivings, Christmases or New Years’. While at first it may be comforting to remember those celebrations, it can also trigger sadness if compared to the current season. An important
Network Health helps local families enjoy the holidays.
t Network Health, we’re thankful for our members and we’re glad to be part of the community. That’s why every holiday season we adopt local families in need. Network Health first began adopting families back in 1999, and the company involvement continues to grow every year. We really enjoy this opportunity to give back to the community. Network Health event organizer and senior business intelligence analyst, Jennifer Resch, says, “I could talk all day about the Adopt-A-Family Program. It is one of my absolute favorite parts of the holiday.” Jennifer has been part of the program since the very beginning, and she’s touched by the difference she makes in family members’ lives. In fact, after thirteen years, Jennifer still has one of the crafts a thankful family member made for her. “That year was very special; we had a great time. It was very personal.”
part of improving your outlook is to accept life’s changes. Don’t judge this holiday based on previous holidays, and you’re bound to enjoy it more. Have Realistic Expectations. Anytime there’s a lot of build up to one specific day, there’s also a risk of being disappointed. It can be nice to look forward to an event or visiting family members, but don’t put too much pressure on it. We set ourselves up for failure if we create unrealistic expectations. So, if you’re not very close with your relatives, don’t expect to see much of a change because it’s a holiday. Instead, take time to enjoy a favorite activity or spend time with a beloved friend or pet. Limit Alcoholic Drinks. The holidays tend to be a time of indulgence, but too much holiday cheer of the liquid form can leave you feeling low. That’s because alcohol is a depressant, and while you might feel better temporarily, the long-term effects will negatively alter your mood. Volunteer. When you’re feeling sad or lonely, it is easy to focus on yourself and harder to think of the less fortunate. But, by helping others, you can also help yourself. Those who volunteer often feel more fulfilled and satisfied with their lives. It is also a good way to socialize and stay connected. There are many opportunities to consider, like the Salvation Army, American Red Cross or local schools and churches. Take a moment to think about the type of people you’d most like to help and call the appropriate organization. Or, if you’d prefer not to formally volunteer, see if there’s a person in your neighborhood who could use a helping hand. Try Something New. Don’t get too wrapped up in old family traditions. It’s easy to feel sad about the past if you allow yourself to get nostalgic about previous customs. Don’t be afraid to try something new. Instead of being worried or stressed about hosting a family holiday, why not enjoy being a guest? Or, if you’re not able to travel to see friends and family, you can start your own tradition. Use the holiday as a reason to treat yourself—that could mean taking in a movie, getting a massage or going to a nice restaurant. By doing something new, you’ll end up enjoying the holiday much more.
Top 5 Holiday Activities Looking for something fun to do this holiday season? Why not try…
1. Holiday Parades Most communities put on holiday parades starting in November. Going to see a parade is fun and a great way to get into the festive spirit. Best of all, they’re free—watch your local newspaper for times and locations. 2. Bright Lights Taking a walk or drive to see a brightly lit neighborhood is a favorite holiday activity for many. Some neighborhoods go all out and create light shows. Ask friends and neighbors for recommendations to find the best spot near you. 3. Community Plays and School Choral Concerts Watching a grandchild’s performance in a play or concert is a heartwarming experience. Even if you don’t have a grandchild performing, it can still be exciting to see, and it’s always nice to support a community-sponsored event. 4. Homemade Baking Is there anything better than the smell of cookies fresh from the oven? Take time this holiday season to prepare your favorite treats. And, if you’d like, you can always bake extra cookies or desserts to use as gifts. 5. Local Museums Many museums give discounts for older adults, and around the holidays they often have unique exhibits to celebrate the season. C oncierge • F all 2012 | 3
health Is It a Cold or the Flu? Know the Difference
t’s hard to avoid getting sick this time of year. It almost seems inevitable. But, do you have a cold or the flu? Telling the difference between the two can sometimes be even harder. The common cold and the flu are both respiratory illnesses, but they are caused by different viruses. The two illnesses have many
Sometimes, usually mild
Usual; higher (100-102°F; occasionally higher); lasts 3 to 4 days
General Aches and Pains
Usual; often severe
Fatigue and Weakness
Usual; can last 2 to 3 weeks
Usual; at the beginning of the illness
Chest Discomfort and Cough
Mild to moderate; hacking cough
Common; can become severe
similar symptoms, making it difficult to tell them apart. In general, the flu is worse than the common cold. Those with the flu will usually have more severe symptoms of body aches, fever, tiredness and dry cough. With a cold, you’re more likely to have a runny or stuffy nose. Most flu symptoms gradually improve over two to five days, but it’s not
uncommon to feel down for a week or more. Both cold and flu viruses enter your body through the membranes of your nose, eyes or mouth. Every time you touch your hand to one of these areas, you could infect yourself with a virus. That’s why it’s so important to keep your hands germ-free with frequent washing.
How to Identify Durable Medical Equipment Fraud
ne of the most common ways older adults are being taken advantage of is through insurance fraud, especially durable medical equipment fraud. This happens when criminals file false insurance claims with Medicare or your health insurance company.
How does it work? Durable medical equipment (such as wheelchairs, scooters, hospital beds, sit to stand or Hoyer lifts, prosthetics and oxygen therapy equipment) must first be prescribed by your doctor. For more expensive items (like those above) your contracted provider must get preauthorization from your health plan to make sure the item is covered. Then, your plan will process the claim and provide payment for the prescribed items. However, some unlawful suppliers are not complying with this process and untruthfully telling members that Medicare or Medicare Advantage doesn’t cover a particular item. When 4 | C oncierge
the supplier doesn’t go through the insurance company, the member is billed directly and pays full price of the item. There are several other ways suppliers illegally take advantage of our members. Be on the lookout for the following. • Billing for duplicate orders • Billing for more expensive items than those shipped • Not giving credit for returned items • Stealing your member ID to file false insurance claims How can you protect yourself? Be informed. It’s always good to understand exactly what equipment your doctor has prescribed to you. This way, you won’t be persuaded to order any unnecessary equipment. Remember–you must get a prescription from your treating physician. You’ll also need to present your health insurance card along with the prescription so the claim can be billed properly. Be careful about which companies you contact. It’s illegal for suppliers to call you directly without prior consent. However, if you give your written consent, suppliers can get around this law. By completing a survey on the supplier’s website or contacting them to inquire about “free” giveaway offers, you are actually giving them authorization to contact you. Once they have your personal information, they are relentless with their calls and attempts to sell
you a product you don’t want or need. Talk to your doctor. To avoid ordering unnecessary equipment, contact your physician first to discuss your medical needs. Double check with Network Health. If a supplier indicates the item you’re looking for is not covered by Medicare, contact us before entering into any written or verbal agreement with the supplier to ensure coverage. Watch your Explanation of Benefits (EOB). This form is mailed to you after your claim has been processed and explains what your insurance company has paid. Make sure to review this carefully, and notify Network Health immediately if you see any charges for equipment that you do not need or did not receive. Remember, one of the benefits of being a Network Health Medicare Advantage member is calling your health care concierge directly with any issues, questions or concerns. If you want to find out if durable medical equipment is covered, always call him or her first. They’ll be happy to help you out. WHAT’S That?
Approval in advance from your insurance company. NetworkHealthMedicare.com
Want to Win a Gift Card?
Tell us what you think about Concierge and your name will be entered into a free, no obligation drawing for a gas gift card. One lucky winner will turn their two cents into $15 worth of free gas. Email your feedback to [email protected] or write to us at Network Health, Attention: Cassie Goodman, 1570 Midway Pl., Menasha, WI 54952. Make sure to include your first and last name as well as the best phone number to reach you. Good luck.
Talking with Your Doc D
id you know if you understand health instructions, you may get well sooner than if you didn’t understand? It’s true. You may also make fewer mistakes when taking medication or preparing for a medical procedure. Informed patients can even manage a chronic health condition more effectively. Just some of the reasons why communication with your doctor is so important. And, many health care professionals recommend Ask Me 3™, a patient education program designed to promote communication and improve health outcomes. The program encourages patients to understand the answers to three questions. 1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this? Ask these three questions next time you discuss your care with your doctor. It can help you be better informed and understand what you need to do to take care of your health.
Understanding Complaints and Appeals
e want to make sure you’re always getting the care you should. If you do not agree with our decisions about your care or what’s covered, you have the right to file an appeal, if you believe the following. • Network Health will not approve or give you care it should cover. • Network Health is stopping care you still need. • Network Health has denied payment for services or items you have received that are not covered and you think they should be covered. You must file your appeal in writing within 60 calendar days after the date of the denial. If you have a good reason for missing the deadline, we can give you more time. Who may file an appeal? You or someone you name to act for you (called your authorized representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor or someone else to act for you. To learn how to name an authorized representative, call us at the number below. If you want someone to act for you, you and the person you choose must sign, date and send us a statement naming that person to act for you. How do I file an appeal? Call us at 800-378-5234 (TTY 800-947-3529), Monday - Friday, 8 a.m. to 8 p.m. Or, you can send it to us by faxing 920-720-1908 or writing to Network Health Insurance Corporation, P.O. Box 120, Menasha, WI 54952. What happens after I file an appeal? If you appeal, we will review our decision. After we review our decision, if payment for any of your claims is still denied, we will automatically forward your appeal request to the Centers for Medicare and Medicaid Services (CMS) Contractor (MAXIMUS Federal Services) for an independent review. This is provided by NetworkHealthMedicare.com
Medicare for a new and impartial review of your case outside of your Medicare Advantage organization. If you disagree with that decision, you will have further appeal rights and you’ll be notified of those rights if this happens. How can I file a complaint? If you’re dissatisfied with the service or quality provided by your plan, we’re here to work with you through any issues. You have the right to file a complaint, called a grievance, about how Network Health provided services (not involving an organization determination). Examples of situations appropriate for grievance include: • Difficulty getting through on the phone WHAT’S That?
• Concerns about the quality of care of services
provided • Interpersonal aspects of care (for example, rudeness of a provider or staff) • Failure to respect your rights You can submit your complaint over the phone or in writing within 60 calendar days from the date of the event. We’ll complete a full investigation as quickly as your case requires and let you know the results no later than 30 calendar days from the date we received your request. If we need to extend the timeframe to make a determination, or we refuse to allow an expedited (fast) organization determination, we will let you know about that extension within 24 hours.
Appeal If your plan does not pay a claim that you believe they should,
you can request that they reconsider their decision. C oncierge • F all 2012 | 5
wellness Did You Know
According to the Centers for Disease Control and Prevention, millions of people with prediabetes aren’t aware of their condition.
Limit Your Risk for Diabetes How paying attention to early warning signs can help you avoid the disease.
percent of Americans age 65 and older have diabetes or prediabetes, according to the Centers for Disease Control and Prevention (CDC). But, because prediabetes doesn’t always have symptoms, nine out of 10 people don’t know they have it. All the more reason why it’s so important to know your risk factors and what you can do to prevent type 2 diabetes. What is prediabetes? Prediabetes is when your blood sugar is higher than normal, but not yet high enough to be classified as type 2 diabetes. Without a lifestyle change, 15-30 percent of people with prediabetes will develop type 2 diabetes within five years. If you have prediabetes, the long-term effects of diabetes may already be starting. Those with prediabetes are also 50 percent more likely to develop heart disease and stroke.
What are the risk factors for prediabetes? • Being overweight • Being physically active less than three times a week • A family history of type 2 diabetes • A family heritage of African American, Hispanic/Latino, American Indian, Asian American or Pacific Islander How can I lower my risk for developing type 2 diabetes? Just because you have prediabetes, doesn’t mean you’ll get type 2 diabetes. Healthy lifestyle changes can bring your blood sugar levels back to normal. According to the CDC, modest weight loss and regular exercise can prevent or delay type 2 diabetes in 58 percent of people with prediabetes. Modest weight loss - Losing 5-7 percent of your body weight. This would be 10-14 pounds for a 200-pound person. Don’t worry about
drastically changing your total weight, losing just 10-15 pounds can make a difference. Regular exercise - Exercising moderately for 150 minutes a week. This could be as simple as going for a brisk 30-minute walk five days a week. You can control your prediabetes with a healthier lifestyle. The same lifestyle changes that treat or reverse prediabetes help prevent it too. Prediabetes can also serve as a wake-up call for you to improve your health. But, you’ll never be able to make the right changes, if you don’t have the knowledge. Know the risk factors and make lifestyle changes now. It will improve your life dramatically. WHAT’S That? Type 2 Diabetes The most common form of diabetes, where the body does not produce enough insulin or the cells ignore the insulin.
How Do Health Plans Make Their Decisions?
id you know that decisions made about your care by Network Health are based on the appropriateness of care and service? Care and service include medical procedures, behavioral health services, pharmaceuticals and devices. Decisions are based on written criteria founded on sound clinical evidence and on the benefits outlined in your plan policy, called your Evidence of Coverage. Network Health does not in any way reward any practitioners or other individuals conducting utilization review for denying coverage for care or service. Network Health allows providers to advocate on behalf of members as part of the utilization management program. In addition, the medical director, associates (or designees), care management staff and supervisors of Network Health’s staff receive no financial incentive to encourage decisions that result in underutilization. If you have any questions about the utilization process at Network Health or about a utilization management decision, or would like a copy of specific utilization criteria, call your health care concierge or 800-378-5234 (TTY 800-947-3529), Monday through Friday, 8 a.m. to 8 p.m.
6 | C oncierge
Recap of September Falls Prevention Event
In the last issue of Concierge, we included an article about our participation in Appleton’s Falls Prevention Event. We were just one of several organizations who worked together to bring this valuable annual event to our community. With more than double last year’s participation, it proved to be a success and we look forward to next year.
Healthy Bones at Any Age I
f you completed your annual wellness visit, chances are your doctor has already talked to you about osteoporosis. There’s good reason for it. As you age, your bone density decreases making you more at risk to bone fractures. Fortunately, you can help manage your risk by educating yourself and taking action. Who gets osteoporosis? While older women may have a heightened risk of developing osteoporosis, it is a common disease that affects both males and females. The disease occurs when new bone production can’t keep up with the loss of old bone tissue. What causes it? There are several different factors (such as exercise, diet and genetics) that can contribute to your odds of developing osteoporosis. One of the greatest determiners will be how much bone mass you attained in your youth, because most bone production occurs before age 30. Can it be prevented? Yes. And, even if you’ve already been diagnosed, it’s never too late to take the following steps to help minimize your risk of bone fractures. Get enough of vitamin D. Your body needs vitamin D to absorb calcium. Talk with your primary care physician for his or her recommendation of a daily amount that’s right for you. Include plenty of calcium in your diet. The best way to
get your daily amount of calcium is through food and drinks. Add low-fat dairy, such as yogurt, cottage cheese and milk to your diet. Orange juice, salmon and dark leafy greens can also When grocery shopping, check the orange juice label to make sure it says calcium fortified.
be a good source of calcium. Exercise regularly. Some mistakenly believe that exercising is too dangerous if you have osteoporosis. That simply isn’t true. Exercise is one of the best things you can do for your bone health. Simple strength training and weight-bearing exercises are very effective in minimizing your risk for fractures. Try combining free weight exercises with jumping rope or walking for best results. But check with your doctor first before starting a new exercise routine.
Know your numbers Blood Pressure Near or above goal
High blood pressure
140/90 or above
140 160 180
Near or above goal Less than 150 mg/dL
Borderline High 150-199
Very High 500 or above
60 40 20
Cholesterol Type of Cholesterol
240 or higher
160 or higher
Women: 50 or higher Men: 40 or higher
Women: below 50 Men: below 40
C oncierge • F all 2012 | 7
Meet Your Health Care Concierge To help you get to know your health care concierge a little bit better, watch for a feature on a different concierge in every issue of our newsletter.
“I really feel a sense of integrity here. We genuinely care for our members.” — Marcia Kanne, Health Care Concierge
arcia Kanne is a great example of what the concierge program is all about. She’s knowledgeable, hard working and caring. Chances are when you give her a call, she’ll have the answer. But if not, she’ll get back to you in no time. She is the friendly voice on the other side of the phone that makes the complicated world of Medicare easier to understand. Q: How did Marcia begin her career as a health care concierge? A: Before joining the Network Health concierge team in 2010, Marcia was a Medicare Advantage insurance agent. She always felt more comfortable working with Medicare members because of her experience handling her own mother’s health care and coverage for the past 15 years.
Q: What does Marcia enjoy most about her job? A: “Resolving issues for the member,” says Marcia. She understands that insurance can be complex, but she believes it doesn’t have to be stressful. When a member calls with a question, she makes sure to explain the answer thoroughly. It’s her goal to make sure her members feel comfortable and well informed. Q: Are there any challenges as a health care concierge? A: Marcia explains that one of the biggest challenges is educating members on what Medicare does and does not cover. She also says it is one of the aspects of her job that is most important to her. Marcia works hard to make members aware of all of the resources they have available to them.
M arcia K anne
Q:How is Network Health different from other places Marcia has worked? A: “I really feel a sense of integrity here. We genuinely care for our members” says Marcia. That’s pretty clear from the way Marcia treats her members. “I always let them know that everything is going to be fine and together we’ll figure this out.” Q: How does Marcia spend her free time? A: Marcia is a giver both in and out of the office. When she is off the clock, she enjoys spending time with and caring for her mother. She also looks forward to walks with her dog, Goldie (aptly named, since he’s a golden lab) and taking care of her home in Peshtigo. Currently, Marcia’s on a mission to organize and de-clutter. Maybe if you call and ask really nicely, she’ll agree to do your home next.
Check It Out
We just launched a new website for our Medicare Advantage members. It’s helpful, informative, easy to use and you can learn more about your health care concierge.
isit NetworkHealthMedicare.com and use Research Rx to quickly find what medications are covered and which pharmacies are in-network. Try out the Find a Doctor tool to search for quality physicians, specialists and hospitals that are in-network and close to home. Curious about the premiums and coverage of the other Medicare health plans we offer? In the Available Plans section, you can learn more, compare plans and see the benefits of each plan at a glance. Be sure to explore the Member’s Corner section to get the most out of your health plan. Here you can request condition management materials, find discounts, get help with multiple medications, print the fitness club reimbursement form and much more.
1570 Midway Place, Menasha, WI 54952
Back by popular demand…
Network Health Medicare Advantage members can attend the following performances at the reduced rates below. Catch Me If You Can Thursday, December 20, 2012 at 7:30 p.m. $26 BBC Concert Orchestra Tuesday, February 5, 2013 at 7:30 p.m. $16 This offer is only valid for Network Health Medicare Advantage members and their families. Not valid on previously purchased tickets. Valid while supplies last. To register, log on to eventusher.com and type Medicare in the password field. Then, purchase your ticket by following the simple instructions that appear.
Health or wellness or prevention information
WHAT’S That? Health Care Concierge Your personal Network Health customer service representative. You can always call this person directly.