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Club MED
June 2024
I never know what to get Bev for her birthday or Christmas. Every year, it is the same struggle. I’m sure she wants me to read her mind or be thoughtful enough during the year to notice things she mentions or needs. We are both big boys and girls, so we generally buy anything we need ourselves. I’ve exhausted the theme and bank account over jewelry. At least, I think so. Bev probably does not. She likes cash. There is no doubt about that. So, do I. My own and keeping it. I prefer something more meaningful rather than a cold exchange of value. The three kings did not bring their debit cards to the creche. Joseph wasn’t operating a Square credit card swiper in the corner of the stable. As usual, Bev is not very cooperative. Mrs. Grimmond’s Christmas Gift Choosing the Right Gift This Time
“Ok, that breeder. So?” I asked.
to remember someone on the list he had forgotten.
“I already said it. The breeders have a new litter. You said you wanted to get a Vizsla.”
Bev finally said the words I was waiting for. “We don’t want to jump into this. Remember the bad dog my daughter got? We don’t want that.” “Absolutely!” I saw my way out. “YOU’RE RIGHT,” I repeated in case she didn’t hear. She likes it when I say she’s right. “We need to think this through and ponder the consequences,” I responded.
I thought to myself, I say I want lots of things. I would like a Corvette, I would like more Whoopi, I would like dinner ready when I get home. None of those things seem to materialize. I didn’t say that, of course. I knew better.
I said, “I thought you said no more dogs last week when I brought up the subject?”
“We need to check out the puppy,” she reiterated. “I couldn’t agree more,” I said.
“They are so cuuuuuuuuuuuute! Do you want me to send you a video from their website?” Bev said.
Then I backpedaled. I smelled a trap. “Do you mean see the dog in person?” I sputtered. “It’s a busy time of the year with the Christmas holidays. They probably don’t have time. Christmas is just a few days away.”
“Not really. I’m busy working,” I replied.
“I already texted it to you. Look!” Bev ordered. “I knew you would want to see it. Besides, you said Max needs a buddy because he is so lonely when Bella is not here. You said Max is depressed, and you don’t want Max to be depressed. You said Max wants a little buddy.”
If I could stall, the puppy fever might break.
“I’ll check with the breeder,” Bev said, then hung up before I could say, “I got to get back to work.” I was sure the breeder would put us off until after New Year’s. I was feeling safe. Two minutes later, the phone rang. “We’re on for five o’clock this evening,” Bev said. “Today?” I burst out. “I’m busy.” “Be home by five,” Bev ordered. “I’m driving. Don’t be late.” She hung up again before I could respond.
I hate it when she uses my words against me.
“Did you get this in writing from Max?”
I got a call the Monday morning before Christmas when I was at work.
I could tell I was losing this argument.
“The breeder in Lincoln who raises Vizslas has a new litter.”
“Don’t be that way. Watch the video. You know you want another dog. They are so cuuuuuuuuuuuuuuuute. Look at the video,” she insisted.
I had Bev on speakerphone and was working through the morning’s emails. “Who has what?” I said, not understanding what she said.
In sales, we call this the assumptive close.
I watched the video. I knew I was screwed.
I told Angie what had transpired. “You’re going to SEE the puppies?” she said, like you’re the dumbest man in the world. “It looks like you’re getting a puppy for Christmas,” she said matter-of-factly. I tried to keep it upbeat and positive. “We’re only looking,” I said in my defense. Angie gave me the look, “Right, only looking.”
I told her, “Bev, those puppies are already called for before they’re even born. There is a waiting list.” She came back. “That’s why I’m calling you. Someone backed out of the deal. There is one little girl left.”
“There is a dog breeder in Lincoln who raises Vizslas. We talked about this.”
I always wonder if we actually talk about things, if she imagines we talk about things, or if she is out-and-out lying. I have no way to prove it one way or the other. I’ve been doing this long enough, however, to know not to argue with her. So, I agreed.
I was thinking fast now. I thought I could call the breeder and offer him $200
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Medicare Insurance Made Easy
402-614-3389 • 1
NEW RULE, NEW TOOL FROM HEALTH & HUMAN SERVICES FIXING PRIOR AUTHORIZATION DENIALS
Prior authorization has arisen as an issue for Medicare Advantage Organizations and Medicaid states. According to consumer claims, consumers are denied needed coverage unnecessarily. You can imagine the pain and hardship this causes. What if there was a Medicare prior authorization tool doctors, insurance companies, and patients could use to communicate with one another? Congress recently conducted hearings on prior authorization denials, and the Department of Health & Human Services (DHHS), which is the ultimate supervising authority for Medicare (CMS) and Medicaid, issued a final rule that offers a partial solution to the problem. DHHS initiated the creation of a Medicare prior authorization tool to speed up the process and reduce errors. THE DHHS FINAL RULE The DHHS mandated the establishment of a standardized electronic platform for exchanging medical and billing information between payers (insurers and states, for Medicaid), providers, and consumers. All three will be able to see prior authorizations while in process in real time and interact with one another. Doctors will see their prior authorization submission as the payer (insurance company) processes the prior authorization. They will see if codes are incorrect or documentation is missing; if denied, doctors will see the reasons. Payers will see additional information added and corrections made to the prior authorization requests in real time. They can track the prior authorization because there is a timeline they all can see. Payers can see the medical history and even similar prior authorizations approved or denied for the patient.
Payers can better coordinate with other payers when other insurance companies may be involved. Consumers can see that the doctor’s office is actually submitting for the prior authorization and where it is in the process rather than calling the provider to check in. DHHS aims to create a more efficient, responsive, and transparent system than the current process for prior authorization. This electronic platform will be for: • Medicare • Medicaid • Affordable Care Act (ACA) Marketplace • CHIP (Children’s Health Insurance Program) The platform is called Application Programming Interfaces (API). While it will be for government-sponsored health plans and not private insurance, like employer health plans, these types of institutional changes usually trickle down to the private sector eventually. WHAT’S ON THE APPLICATION PROGRAMMING INTERFACES (APIS)? Providers, payers, and consumers will be able to look up: • Medical items and services that require prior authorization. • Required documentation for the plan to make a prior authorization decision. • Current status of a prior authorization decision. The API (Application Programming Interface) is the Medicare prior authorization tool that allows providers and payers to communicate quickly and easily and consumers to monitor the process.
• Prior authorization status • Date of approval or denial of a prior authorization request • Date or circumstance when the prior authorization ends. • What items or medical services were approved
• Reason for denial, if denied • Administrative and clinical
information submitted by a provider.
This could also include information about past prior authorization decisions beneficial to a patient who is required to obtain prior authorization again for the same service when switching health plans. MEDICARE PRIOR AUTHORIZATION TIMEFRAMES Currently, Medicare Advantage Plans can take up to 14 calendar days for a standard decision. Expedited decisions must be completed within 72 hours of the request for medical treatment. With the final rule, prior authorization timeframes were shortened to seven calendar days, and the same 72- hour rule was used to expedite prior authorization decisions. REASONS FOR DENIAL The plans must explain the denial to the provider and patient through the APIs. This was not always done, especially if the denial was for miscoding or lack of supporting documentation. Now, the patient can see the denial. They do not need to rely upon the doctor’s office to explain what the insurance company did or didn’t do, particularly if the provider’s back office did not provide adequate documentation. Everyone can see what the other one is doing or not doing.
Everyone can also see what can be done to appeal or overturn the denial.
The prior authorization details available through the APIs will include:
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2 • OmahaInsuranceSolutions.com
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“Thank you Christopher! You made the whole process of choosing a Medicare supplement easier and less confusing. I appreciate your knowledge and Testimonial
PUBLIC REPORTING OF MEDICARE PRIOR AUTHORIZATION BECAUSE OF THE TOOL Insurance companies will be required to report their denial ratios on their website. Consumers will be able to see how often insurance carriers deny prior authorizations and thus determine which Medicare Advantage plan or other government-sponsored programs to choose. The hope is that Medicare Advantage Organizations (MAO) will be motivated to improve the prior authorization processes through education, better technology, and more efficient and robust systems.
The data required to be listed on the payer (insurance company) website will be:
professionalism. You are a great asset to all of us ‘young at heart’ clients! I will give your name and number to my eligible Medicare friends. Thanks again.” –Lisa G.
• List of all items and services that require prior authorization. • Percentage of standard and expedited prior authorization requests approved and denied (aggregated for all items and services) • Percentage of standard prior authorization requests that were approved after appeal. • Percentage of standard and expedited claims where decision timeframes were extended and then followed by a request approval. • Average and median timeframes between a prior authorization request and a decision for standard and expedited prior authorization requests. IMPLEMENTATION JANUARY 2027 As with any government legislation and systemic changes, time is required. The DHHS final rule set the effective date for the proposed regulations for January 2027 .
Delightful Banana Bread
This comforting, fruity favorite transforms overripe bananas into a moist, delicious treat perfect for breakfast or a snack. Ingredients • 2 cups all-purpose flour • 1 tsp baking powder • 1 tsp baking soda • 1/4 tsp salt • 1/2 cup butter, softened • 1 cup granulated sugar • 2 large eggs • 2 cups mashed ripe bananas • 1/2 cup chopped walnuts (optional) Directions 1. Preheat oven to 350 F and grease a 9x5-inch loaf pan. 2. Combine flour, baking powder, baking soda, and salt in a medium bowl. 3. In a large bowl, beat butter and sugar until light and fluffy. 4. Add eggs and mashed bananas and mix until blended. 5. Gradually add dry ingredients to wet ingredients, stirring until blended. 6. Stir in walnuts. 7. Pour batter into prepared pan. 8. Bake for 65–70 minutes or until a toothpick inserted into the center comes out clean. Let cool before serving.
Building a system as large as the API takes time to provide an effective and robust tool for the Medicare prior authorization process.
Bottom Line: Medicare Prior Authorization Tool
I find this awesome. Too many times, consumers are in the dark. All they know is they can’t get their treatment. They do not know the truth. Is this something Medicare covers? Did the doctor’s office submit the request correctly, and did they fight to approve it? Is the insurance company being unreasonable? Can I do anything?
It is hard to bluff when everyone can see everyone else’s cards. Light is the best disinfectant for an infection.
402-614-3389 • 3
11414 W. Center Rd., Suite 250 Omaha, NE 68144
PRSRT STD US POSTAGE PAID BOISE, ID PERMIT 411
402-614-3389 OmahaInsuranceSolutions.com Chris@OmahaInsuranceSolutions.com
Code 80362_052224_MK
INSIDE This Issue
1
How I Chose the Perfect Christmas Gift
Medicare Offers New Prior Authorization Tool
2
Delightful Banana Bread
3
Ginger Spice
I tried to chat with Bev during the drive to Lincoln. There was no chatting. She was a woman on a mission. Absolute focus. It was scary. When we arrived, my worst nightmare. A cute puppy. In terms of marketing and sales, puppy sales have to be the biggest Pickup and Delivery job in the world. All you must do is present the puppy. The dog is the salesperson. I was so screwed I thought I should roll over on my back and give up. It was the cuuuuuuuuuutest dog in the world. Maybe I should offer to give away a puppy with every Medicare Supplement. With Bev’s auburn hair and the puppy’s amber coats, they were a color-coordinated ensemble. The breeder/mom pointed out the obvious. “You’re a perfect match.” ... CONTINUED FROM COVER
At the end of our visit, I made one last attempt. I said to Bev in a hushed voice, “Is the dog’s personality okay?” “Yes!” she said emphatically. The floor went to me, and I sheepishly reached for my wallet. “Cash or credit card,” I said. “I don’t have a checkbook with me.” “We like cash,” the breeder couple said in unison. Of course, you do, I thought. I said, “My wife needs time to get things ready at home for her new dog. Can I pick her up in a few days?” I was quickly corrected. “WE need to get things ready for OUR beautiful puppy,” Bev restated. Bev said, “We need a kennel that fits, toys, chewies, and, did I say, toys, special puppy food. Do you recommend any particular dog food for her?” “Yes, we do, though it is a little expensive.” Of course, it is, I thought. “We’ll send you a link. You can order it through us.” “Aren’t they thoughtful?” I whispered to Bev.
There was a micro-frown telling me to knock off the sarcasm.
I handed over a cash deposit with a promise to return on Friday to pick up “our puppy” and drop off the final payment. As we were leaving, Bev gave Ginger Spice, which became her name, a long hug, and Ginger Spice, on cue, gave her a face bath of affection. Bev was like a little girl getting her first puppy. I have rarely seen Bev so happy. I realized at that moment that I would be content to pick up dog poop for the next 15 years to see her with such joy in her heart for Christmas.
This year, I chose — reluctantly — the right gift for Mrs. Grimmond.
–Christopher J. Grimmond
4 • OmahaInsuranceSolutions.com
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