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Club MED
May 2024
Reaching Across the Isolation And Taking Stock of the Crisis Moments
I was in an emergency room a few days ago. It was a hodge-podge of enclosed desks, hallways, and niches with chairs. No coffee. No water.
A lady came in by herself teary-eyed. You noticed her because she was moving faster than everyone else, and she was alone.
Hard to find the bathroom. Not an aesthetically pleasing office space.
You could tell she just found out the news and had rushed to the emergency room. A man met her and directed her to some people huddled in the corner of the waiting room. I was alone with my own thoughts. Even though I was seated next to my wife, Bev. I was alone. She was alone. We said a few words to one another, but mostly we were silent and waiting. Our thoughts were our only companion. Lots of thoughts. Mostly I was thinking and waiting for “next.” What will we find out next?
The people working were neutral. Not friendly.
Not unfriendly. They only engaged you if you spoke to them. Then, the bland eyes focused and noticed.
I sat on a bland chair near the entrance, waiting. People came in. They were either couples or a group of three or four. Everyone was soft-spoken and clustered with their group. Conversations were minimal.
All of the people in the waiting room were alone. The sense of isolation in the midst of shock and fear is profound.
The walls were beige, the tile floor was beige. It was the most colorless space in the world.
I reached out to hold my wife’s hand. Connected. But still alone.
Humans are built to survive. To survive as individuals. To survive as a family. To survive as a tribe. When the switch is flipped because of danger, it is very isolating. Every week, we get phone calls at the office. Clients call with questions and problems. Sometimes, they call with messages of danger. Their spouse has cancer. Their mother fell and broke a hip. Their father died. With danger and tragedy, there are usually questions and problems to solve.
I’m all about logic and solving problems. Angie, my assistant, has a big heart with a lot of compassion. Her conversions are always better.
I’ll certainly be more conscious of the numbing isolation people feel in their crisis moments going forward. Hopefully, it will have a permanent effect on my behavior. I will more consciously reach out to cross the barrier of isolation.
The world is full of noise and busyness. It keeps us distracted 24/7 until danger strikes. It is amazing how profound the isolation is.
–Christopher J. Grimmond
Medicare Insurance Made Easy
402-614-3389 • 1
THE PHYSICAL AND MENTAL GAINS OF RETRO WALKING REVERSE YOUR ROUTINE
Psychologists and self-help gurus say it doesn’t help to dwell on where you’ve been. But what if walking backward — literally — could benefit your health? According to a 2023 CNN health report, walking backward is a unique exercise regimen with potential advantages for your joints. Contrary to traditional forward walking, retro walking, as it is often referred to, engages different muscle groups, fosters improved balance, and contributes to overall fitness in various ways. One of the primary benefits is the engagement of muscle groups not heavily used in forward walking. When walking backward, you use your hamstrings, calves, and glutes to a greater extent. This variance in muscle engagement can lead to enhanced strength and toning, providing a good workout.
Retro walking challenges both brain and body to adapt to a different spatial orientation, enhancing coordination. For older adults looking to maintain or improve their balance, retro walking can be a tactic to reduce the risks of falls and related injuries. Just start slow. The psychological benefits of walking backward also cannot be overlooked. It’s just plain fun to walk backward, and the low stakes of this exercise can excite those doing it to continue adhering to it. While walking backward may seem unconventional, the benefits are compelling. From targeted muscle engagement to reduced joint impact and enhanced balance, incorporating retro walking into your fitness routine can be a valuable addition. As always, it’s best to ask your primary care physician if it would suit your unique needs.
Walking backward can be particularly beneficial for those recovering from injuries and/or dealing with joint issues. The unique motion of retro walking puts less strain on the knees, making it a safer alternative for damaged joints that still delivers cardiovascular benefits through a low-impact workout.
As people age, balance and coordination are crucial components of overall fitness.
DOES TRADITIONAL MEDICARE REQUIRE PRIOR AUTHORIZATION?
People ask, what is the difference between Original Medicare (only Part A & Part B) and Medicare Advantage (or Part C)? Medicare Advantage is managed healthcare, similar to your health insurance policies under an employer health plan. A tool that managed healthcare uses is prior authorization to contain costs. Utilization management first appeared in the 1960s after Medicare Part A was created. Once Medicare Part A was instituted, the number and length of hospital stays skyrocketed. To contain costs, President Johnson and Congress approved the practice of utilization reviews for hospital stays. Utilization reviews confirm the need for hospital treatment: Two doctors need to concur on the diagnosis and the need for hospital treatment. The standard of
treatment was called “reasonable and customary.” What would most doctors consider “reasonable and customary” for this diagnosis? Again, the purpose was to limit unnecessary hospital stays and cut costs. The utilization review process, which gained traction in the health insurance industry, was primarily driven by the need to address issues of medical necessity, misuse, and overutilization of services. As a result, health plans began scrutinizing claims for medical necessity and the duration of hospital stays. In some cases, health plans even mandated that the physician certify the admission and subsequent days after the admission to curb costs. Ironically, Original Medicare operates now with minimal prior authorizations, limited to a few cases involving durable
medical equipment. In contrast, Medicare Advantage, as a managed health care system, necessitates prior authorization for a majority of its procedures and tests, with the exception of routine doctor visits and common practices. Under Original Medicare, the only limit to fraud and abuse of taxpayer-funded resources is the 1-800 number people can voluntarily report fraud to. Medicare Advantage Organizations (MAOs) constantly monitor submissions to make sure the requests for treatment are “medically necessary” as defined by the CMS regulations for standards of care. To make sure the MAOs perform their mission correctly, CONTINUED ON PAGE 3 ...
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Testimonial
... CONTINUED FROM PAGE 2 “CMS oversees an entity’s continued compliance with the requirements for an MA organization. If an entity no longer meets those requirements, CMS terminates the contract in accordance with procedures described in Subpart K at 42 CFR Part 422.” None of us would write a blank check for someone. We want guarantees that our money is spent correctly. Medicare Advantage Organizations (MAO) also oversee that requests for reimbursement for treatments and procedures are within the standards of care that CMS authorizes. An issue has come up recently: Are MAOs too restrictive in their approvals of prior authorizations? After all, on the reverse side, the motivation for profits could motivate MAOs to restrict payments to keep revenue received from CMS for themselves. Unfortunately, CMS does not currently require the MAOs to keep data on some aspects of prior authorization rejections. The two most recent studies are inadequate for giving a real idea. Kaiser Foundation studied 35 million prior authorizations and found that less than 5% (or 2 million) were denied. It also noted that 82% of denials were overturned when appealed. The Health and Human Services Office of Inspector General did a tiny study of less than 250 denials during one week in 2019. Among those denials, the OIG determined that 18% (or 33 cases) should not have been denied. The reasons for denials were not completely clear, though human error and lack of supporting documentation were the dominant reasons.
“After I acknowledged that I was nearing Medicare age, I realized I knew nothing
about it so I reached out to two very informed friends. They both recommended Chris Grimmond. They praised his knowledge and helpfulness so I gave him a call. After meeting with Chris, I was 100% convinced that we would be working together. He answered all my questions and helped me understand the Medicare system. I feel confident I made the right decision to work with Chris and his team at Omaha Insurance Solutions.” –Cheryl A.
Inspired by FoodAndWine.com
Spring Herb Soup With Orzo and Pancetta
An objective and thorough study would be beneficial to dispel misunderstandings and false fears.
Ingredients • 3 tbsp extra-virgin olive oil • 4 oz pancetta, diced • 1 medium yellow onion, finely chopped • Salt and black pepper, to taste • 1/2 cup dry white wine • 1 cup uncooked orzo • 2 large garlic cloves, minced • 1 tsp fennel seeds • 1/2 tsp crushed red pepper
• 8 cups chicken broth • 1 15-oz can cannellini beans, drained • 1/2 cup chopped fresh chives • 1/4 cup chopped fresh tarragon • 1 1/2 cups chopped parsley • Pecorino Romano cheese, grated (for garnish) • Lemon wedges
In my experience, prior authorizations that are denied do not require a formal appeal. The denial is based on wrong codes, insufficient documentation, human error, and a lack of persistence. The real question is not why Medicare Advantage has prior authorization. Instead, it is why Original Medicare does not protect patients and taxpayers from fraud, waste, and abuse with its own prior authorization protocols.
Directions 1. Heat oil in Dutch oven over medium heat. Add pancetta and cook 4–6 minutes. Add onion, salt, and pepper; cook until softened, 8–12 minutes. 2. Add wine and cook 4–5 minutes. Add orzo, garlic, fennel seeds, and red pepper; cook, stirring constantly, 2–4 minutes. 3. Add broth; bring to a boil. Reduce heat and cook until orzo is al dente, 8–10 minutes. 4. Reduce heat to low. Stir in cannellini beans; cook about 2 minutes. Remove from heat. Stir in chives, tarragon, and parsley. Season with salt and pepper. Top with cheese and lemon.
402-614-3389 • 3
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PRSRT STD US POSTAGE PAID BOISE, ID PERMIT 411
402-614-3389 OmahaInsuranceSolutions.com Chris@OmahaInsuranceSolutions.com
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INSIDE This Issue
1
Trying to Cross the Barrier of Isolation
2
Retracing Your Steps for Better Health
Prior Authorization Would Protect Taxpayers
2
Spring Herb Soup With Orzo and Pancetta
3
Explore the Historic Fortifications of the Highlands
4
Defending the Highlands Scotland’s Must-See Castles
From the heights of Castle Hill to the idyllic waters of Loch Duich, the historic castles of Scotland stun tourists and history enthusiasts alike. Today, these castles are well-maintained and ready to receive visitors from around the world. If you want to explore the beauty of the highlands from the rocky ramparts of Scotland’s greatest castles, these are three landmarks you need to visit. EDINBURGH CASTLE Located amidst Edinburgh’s Old Town — a World Heritage Site — the daunting and long-standing Edinburgh Castle on Castle Hill is a bulwark that has defended the Scottish capital for nearly a millennium. The military still uses parts of the formidable ramparts, but the rest serves as a can’t- miss tourist destination. The castle also
houses the Crown Jewels of Scotland, known as the Honours, and famed cannons, like Mons Meg, one of the grandest pieces of medieval artillery ever constructed and given to King James II in 1457 A.D. DUNNOTTAR CASTLE Dunnottar Castle is located on the northeastern coast of Scotland and is surrounded on three sides by the waters of the North Sea. There is evidence that ancient Picts lived in the area long before a monastery was consecrated on the grounds in 1276 A.D. In 1392, Sir William Keith seized the holy site’s strategic location by building its first stone fortification, The Keep. An even more unorthodox move came in 1593, when George Keith, the 5th Earl Marischal, built The Lion’s Den at Dunnottar Castle to house his pet lion.
EILEAN DONAN CASTLE There is a reason Eilean Donan Castle is one of the most photographed castles in the world! Situated on a tiny island at the mouth of Loch Duich, this formidable fortress began as a monastery in 634 A.D. before being converted to a fortress in the 12th century to protect the area from Viking raids. Now administered by the Conchra Charitable Trust, this castle houses rare artifacts, such as a sword rumored to be from the famed battle of Culloden in 1745.
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