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S U M M E R
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P U B L I C A T I O N
O F
L I F E , H E A LT H & W E L L N E S S
I got through it the first time and I’ll do it again. With strength and support, Network Health member Don Sipe is now a cancer survivor.
3 Coverage That Goes Where You Go
We have you covered when you’re away from home
4 Make Your Medications Work Better The importance of taking your medications as prescribed
E DITORIAL STAFF
Chief Administrative Penny Ransom Officer
5 Help Prevent Opioid Abuse
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Dependency on opioids is a growing problem in Wisconsin
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5 Member Rights and Responsibilities
Your rights as a Network Health member
6 Make No Bones About It
Detecting osteoporosis early can save you in the long run
President Coreen and CEO Dicus-Johnson
Marketing Jessica Coordinator Thomaschefsky
Lead Designer Debra Sutton
EDITORIAL BOARD Lisa Endl, Melanie Draheim, Stacy Schwandner, Alice Parks, Theodore Regalia, Kimberly Swanson, Kacey Werner, Angela Keenan Balance is published by Network Health. The health information contained in Balance is meant to supplement, not replace, the advice of health care professionals.
7 Evaluating New Technologies
Network Health evaluates new technologies on a regular basis
© 2017 Network Health. No portion of this newsletter may be reproduced without written permission from Network Health. S T O
C O V E R
STRONGER
Y
08 12 Treating Common
THAN CANCER
With strength and support, Network Health member Don Sipe is now a cancer survivor.
15 The Importance of Completing
Summer Ailments
a Health Risk Assessment
Help identifying and treating common summer ailments
Identify potential health risks that could lead to something more serious and costly
12 Do You Need Help
16 Schedule and Track Your Child’s
Submitting a Claim
Preventive Screenings
How to arrange for reimbursement
Overall wellness and preventive services for your child
13 How Network Health Finds
Quality Doctors
Evaluation process for finding quality providers
13 Access and After-Hours Care
Timeliness for medical and behavioral services
14 Beware of Scams
Keep your financial and insurance information safe
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18 Your Input Is More Valuable
Than You Know
Let us know how you feel about your benefits and health care providers
TELL US WHAT YOU THINK If you have questions or suggestions or would like to tell us how Network Health improved your life, send us an email at balance@networkhealth.com.
You can also write to us at: Network Health Attention: Jessica Thomaschefsky 1570 Midway Pl. Menasha, WI 54952
HAVE A QUESTION?
Call our award-winning customer service team. HOURS Mon., Wed.–Fri.: 8 a.m. to 5 p.m. Tuesday: 8 a.m. to 4 p.m. PLANS THROUGH AN EMPLOYER 800-826-0940
19 Easy Access to the Information
PLANS FOR INDIVIDUALS AND FAMILIES 855-275-1400
You Need
New self-service features coming soon
WANT MORE HEALTH TIPS?
19 Join Our CoCreate Movement Help us build a better health insurance experience
Check out our blog at copilotwi.com. We add helpful information about health and well-being every week, so be sure to visit often.
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life. health. wellness.
Coverage That Goes Where You Go
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vacation can turn into an unexpected adventure if you or a family member gets sick or injured. Don’t worry, Network Health has you covered when you’re away from home.
EMERGENCIES
If you have a medical emergency when you’re outside the service area, call 9-1-1 or get to the nearest emergency room. You have health care benefits for emergency situations such as heart attacks, excessive bleeding, head traumas, broken bones or seizures. When out of the network area, you’re covered for an emergency hospitalization until you can be moved to a participating Network Health facility, as long as you let us know about your emergency within 48 hours of being admitted into the hospital. To do so, contact our customer service department. Available hours and our phone numbers are listed on page two. Be sure to show your Network Health member ID card when you check in.
URGENT CARE
You’re covered for urgent care situations like minor injuries, stitches, possible strep throat or ear infections when you cannot travel safely to your primary doctor. If you are outside of Network Health’s service area and you need to see a doctor but it isn’t an emergency, you can still visit a hospital or an urgent care clinic. However, if the doctor or facility is not in our network, you’ll need to notify us within 48 hours of receiving care. n e t w o r k h e a l t h . c o m
FOLLOW-UP CARE
Your primary doctor, or other in-network provider, must be seen for your follow-up care. If this isn’t possible, and you visit a doctor or hospital not in our network, you’ll need to call us for approval within 48 hours of treatment.
PAYMENT FOR CARE
Some medical facilities outside Network Health’s service area may require you to pay for your care at the time it’s provided. To get reimbursed, send the itemized bills and proof of payment within 90 days of receiving care to the following address.
Network Health Attn: Claims P.O. Box 568 Menasha, WI 54952 Visit networkhealth.com/search/doctors to find in-network providers by specialty, name or location. S u m m e r 2 017
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life. health. wellness.
Make Your Medications Work Better According to the Mayo Clinic, almost 70 percent of Americans take at least one medication, and more than half take at least two.
N
ot taking your medications exactly as your doctor prescribes is the main reason treatments fail, leading to worsening symptoms, more time spent in the hospital and higher health care costs. Reasons for not taking medication as prescribed vary from person to person. Here are the most common reasons. Forgetting to take medication Cost of medication Side effects of the medication If any of these reasons apply to you, make sure to speak with your doctor to discuss your options. To make sure your medications continue to work effectively, you and your doctor should evaluate your medications, review lab tests and check your health status. As part of this plan, you can help by scheduling and attending regular appointments and having necessary lab tests. It’s important to know why you take the medications you do. For example, many members take over-the-counter aspirin for heart disease to help prevent a heart attack. If you take aspirin, know the proper dosage and frequency as well as the benefits, risks and potential interactions. Most medications have various side effects, so it’s important to understand what risks are associated with your medications. For example, high blood pressure medications like lisinopril (ACE) or losartan (ARB) have common side effects including dizziness, diarrhea and vomiting. Diuretics like Lasix or hydrochlorothiazide (more commonly known as “water pills”) are prescribed to adjust body fluids, and your doctor will want to monitor the dosage and how your body is reacting to the medication. Heart medicines such as digoxin should be monitored regularly by a doctor to make sure they are prescribed at a “therapeutic” level. Maintaining a therapeutic level ensures that the amount of medication in your body is at a sufficient level to help stabilize your cardiovascular system. Doctors also need to monitor how your body is reacting to the illness and any persistent or long-term medications. Your doctor may prescribe lab tests because long-term prescriptions can affect organ function. Members who have heart disease may 4 | balance • S u m m e r 2 017
require a regular blood test to evaluate potassium levels and heart function. Those who have kidney disease may need a creatinine level as a part of their treatment plan. During future visits, your doctor will use lab results and the updated history you provide to monitor for signs of harmful effects. He or she may simply adjust the dosage or prescribe a different medication. Together, you and your doctor can ensure your medications are working properly to maintain or improve your health. Use this list of questions and tips to help make sure you’re doing things right.
UNDERSTAND
If you don’t know or understand the answers to the following questions, ask your doctor or pharmacist for instructions. Why am I taking this drug? How and when should I take it? How should I store it? What are the possible side effects?
ORGANIZE
If you take multiple medications, create a list to help you remember the instructions for each. Use a pill box to keep your medications in order. Make a list of questions you have about your medications and bring the list to your next doctor’s appointment.
AVOID
Don’t alter the amount of a medication you take unless your doctor approves it. Don’t take your medication for any symptoms it wasn’t prescribed for. Don’t take someone else’s medications and don’t give your medications away. Prescriptions are specific to each individual’s health and wellness. Never stop any medications prescribed by your doctor without their approval. Discontinuing some medications suddenly can cause serious medical issues and withdrawal effects. networkhealth.com
Help Prevent Opioid Abuse N
o one likes talking about substance abuse, but it’s a growing problem in Wisconsin. According to the Wisconsin Department of Health and Human Services, more people died from opioid overdoses than car crashes in 2015. Opioids are narcotic medications that are used to treat mild to severe pain and any of us could fall victim to a dependency on opioids if they are not taken as directed.
Do you have any of the following medications in your house?
Oxycodone Morphine Fentanyl Meperidine
Hydrocodone Codeine Hydromorphone Methadone
These prescription painkillers are some of the most commonly used opioids. If you have been prescribed opioids, use them only until pain is manageable with non-narcotic pain relievers. Keep opioid medications locked up, and dispose of unused medications as soon as they are no longer needed. Resist the urge to save them “just in case.” And, beware of Propoxyphene. It’s an opioid that was removed from the market several years ago and should no longer be used at all. Make sure you are disposing of the drugs properly. Flushing or draining the drugs can contaminate our water supply. Instead, you can get rid of unused prescription medications by doing the following. Dropping them off at a local police department (call ahead to make sure you know exactly what they accept) Use the Wisconsin DEA’s mail-back program Attend a drug take back event To learn more about how to return unused opioids, visit doseofrealitywi.gov/drug-takeback. If you have questions or would like to speak with a representative from Network Health, please email us at QI@networkhealth.com.
Member Rights and Responsibilities
Do you know your rights and responsibilities as a Network Health member? To learn more about how we provide you with service that respects your rights, go to networkhealth.com/rights or call the appropriate customer service number listed on page two if you’d like a hard copy. n e t w o r k h e a l t h . c o m
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life. health. wellness.
Make No Bones About It
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id you know more than 40 million people in the United States either have or are at risk for developing osteoporosis? Osteoporosis is a disease which causes bones to thin, weaken and become more fragile. This can lead to bad breaks and painful fractures. The good news is, osteoporosis can be detected and treated. A bone mineral density (BMD) test determines how much bone mineral content (calcium and other minerals) is present in a bone. The higher the mineral content, the denser the bone is. The denser the bone, the lower the risk of fracture. A BMD test can alert you to any changes in bone density, diagnose osteoporosis, gauge effectiveness of measures taken to improve density, assess fracture risk and target steps that need to be taken. A BMD test is not the same as a bone scan. The preferred method for measuring bone mineral density is with dual X-ray absorptiometry (DXA) or dual energy X-ray absorptiometry (DEXA). DXA is pain-free and can be completed in less than 30 minutes. Radiation exposure during testing is very low. The bones that are most likely to break due to osteoporosis are the vertebrae, hip, wrist, forearm and heel. These are the bones that receive density testing most often. The loss of bone mineral density increases each year. Getting a BMD test is a good idea for women over 50 who have had a fracture. Testing is recommended within six months of the bone fracture (unless a test was completed within the previous two-year period). Depending on certain risk factors, a doctor may suggest a BMD test every two years. Following are other risk factors that should be discussed with your primary doctor when assessing the need for a BMD test.
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Detecting Osteoporosis Early Can Save You in the Long Run
n Short stature (64 inches or less) or loss of height n Low calcium and vitamin D intake n Sedentary lifestyle n Postmenopausal women n Decrease in hormone levels n Close relative with osteoporosis or history of broken bone(s) n Smoking n Alcohol use n Transplant recipient n History of a fractured bone after age 50 n Medications being taken that may contribute to bone loss The presence of certain diseases or conditions can also be considered a risk factor. The following diseases should be disclosed and considered in conversations with your doctor about a BMD test. n Alcoholism n Multiple sclerosis n Allergies n Rheumatoid arthritis n Anorexia nervosa n Asthma n Cancer n Cushing’s disease n Diabetes n Hyperparathyroidism n Hyperthyroidism n Inflammatory bowel disease n Lactose intolerance n Lupus n Liver disease n Kidney disease n Lung disease Treatment Osteoporosis treatment focuses on proper nutrition, exercise and safety to prevent falls that may result in fractures. In addition, your doctor may prescribe a medication to slow or stop bone loss, increase bone density and reduce fracture risk.
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Evaluating New Technologies N
etwork Health evaluates new technology and new applications of existing technologies on a regular basis. This includes the evaluation of medical procedures, drugs and devices. Decision making on technologies is based on, but not limited to, the following. n FDA approval n Manufacturer information n Scientific evidence n Peer-reviewed articles n Opinion of contracted providers n Risk/benefit analysis n Government regulatory agencies n Assessments performed by agencies specializing in technology
New technologies are reviewed by a group of participating physicians and health plan staff (Medical Policy Committee) who make recommendations for inclusion as a covered benefit. The following technology assessments have been reviewed over the past 12 months. n OPTUNE Device (The OPTUNE device is a tumor treatment fields [TTF] therapy for glioblastomas, a type of brain tumor.) • This technology remains experimental and investigational n Flexitouch System for Lymphedem (The Flexitouch System is a programmable segmented pneumatic compression device.) • This technology remains experimental and investigational. If you have a question about a technology assessment, contact our care management department at 800-236-0208 (TTY users call 800-947-3529), Monday through Friday between 8 a.m. and 5 p.m. Bilingual language assistance or translation services are available. S AY W H AT ?
Glioblastoma – a tumor that forms from supportive tissue of the brain and spinal cord
Lymphedema – abnormal collection of high-protein fluid beneath the skin that occurs most commonly in the arm or leg, but also may occur in other parts of the body n e t w o r k h e a l t h . c o m
f you’ve been diagnosed with chronic bronchitis, emphysema or chronic obstructive pulmonary disease (COPD), let us help. Breathe at Ease is Network Health’s proactive condition management program designed to help members avoid flare-ups, control symptoms and potentially improve their lung conditions. It’s intended to supplement a physician’s care with one-on-one support from a respiratory therapist. Breathe at Ease received the 2016 Innovation Award from the Wisconsin Society of Cardiovascular and Pulmonary Health & Rehabilitation. To learn more, visit networkhealth.com/Breathe. Breathe at Ease is available at the following locations. St. Elizabeth Hospital Attention: Robyn West, RRT 1506 S. Oneida St., Appleton, WI 54915 Phone 920-831-1498, Fax 920-831-1281 robyn.west@ascension.org Mercy Medical Center Attention: Robyn West, RRT 500 S. Oakwood Rd., Oshkosh, WI 54904 Phone 920-831-1498, Fax 920-831-1281 robyn.west@ascension.org Affinity Medical Group New London Attention: Robyn West, RRT 1420 Algoma St., New London, WI 54961 Phone 920-831-1498, Fax 920-831-1281 robyn.west@ascension.org Calumet Medical Center Attention: Peggy Nolan, RRT 614 Memorial Dr., Chilton, WI 53014 Phone 920-849-1816, Fax 920-849-7529 peggy.nolan@ascension.org Holy Family Memorial Attention: Sandy Bauman, CRT and Lori Newberg, CRT 2300 Western Ave., Manitowoc, WI 54220 Phone 920-320-4247(4AIR), Fax 920-320-3043 sbauman@hfmhealth.org or lnewberg@hfmhealth.org
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S T O C O V E R Y
Don Sipe and his wife, Paula
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networkhealth.com
THAN CANCER When a rare form of cancer threatened to take Don Sipe’s life, his Network Health care manager helped him get the care he needed from a world-class cancer center. > > > By Jessica Thomaschefsky P h o t o g r a p h s b y B e t h D e s J a r d i n , Tr ove P h o t o g r a p hy
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D
on Sipe and his wife, Paula, originally from the Appleton area, relocated to the Milwaukee area to be closer to their children and grandchildren. Living in Oak Creek wasn’t only good for their family, it also meant they were closer to world-class care at Froedtert Hospital. Don and Paula have four children, the youngest are twins, nine grandchildren and two more grandchildren on the way. Don worked at RR Donnelly for over 30 years making plates for printing presses. A year and a half into retirement, Don was diagnosed with intrahepatic cholangiocarcinoma. This rare form of cancer is found in the bile duct of the liver. Many times the signs and symptoms go unnoticed until the cancer is in such an advanced stage that surgery is no longer an option. Because of this, the only treatment option is an organ transplant. In early 2016, Don and Paula were sharing a meal with their son when he mentioned to Don that his eyes looked yellow. Don wasn’t feeling ill and didn’t think much of it. Paula made him drink a lot of water the next day thinking the yellowing would go away on its own. The next day he wasn’t looking any better so she called the doctor to make an appointment. By the time they had arrived for the appointment, Don’s eyes and skin were even more noticeably yellow. The Sipes were planning on leaving for a vacation in Florida and were hoping this would be a quick and easy appointment so they could be on their way. However, an ultrasound and CT scan showed cancer cells and Don went into surgery right away. He had biliary drains inserted into his liver to save his life. “We didn’t know what stage he was at or anything,” Paula said. Once all the biliary drains were in place, there was nothing more to be done because of Don’s cancer stage. He was then referred to a specialist at Froedtert Hospital & Medical College of Wisconsin in Milwaukee to seek further treatment. The couple was amazed at how quickly they were able to get an appointment with a specialist. “The doctors really pulled some strings to get Don in as soon as possible,” Paula said. Once at Froedtert, the Sipes were overwhelmed by the large facility. But once they met Don’s cancer team, they were instantly put at ease. “The people at Froedtert were excellent, they explained everything well and reassured us,” Don said. “There was no doubt that we were in the right place,” Paula said.
“
The people at Froedtert were excellent, they explained everything well and reassured us,
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-Don Sipe
Don began chemotherapy treatments once every two weeks for six months while he waited for a new liver. During that time, the Sipes met with a social worker to go over the qualifications to be put on the transplant list. The social worker asked a series of questions including what kind of support Don had at home, if he had people who could take care of him, his lifestyle habits and many more. The medical testing to see if he was a strong candidate started in January of 2016, and every part of Don’s body was tested. He 10 | balance • S u m m e r 2 017
was approved for the donor list after he passed all of the testing and requirements in April of 2016. Eight months later, Don received a call that they had a liver but he was second on the list. In transplant situations, they always notify the first two candidates on the list and have them both come to the hospital. Once at the hospital, Don underwent an 18-hour preparation which included giving 27 vials of blood. Despite all the prep, he was told the person on the list before him made the match and he was sent home to wait once again. “We were disappointed, but at least we knew that you actually get a call and there is a possibility,” Paula said. Miraculously, a few days later he received another call and was the first person on the list for a new liver. He went through another 18-hour prep and this time had the surgery. Don was monitored for a few days after surgery to make sure his body accepted the liver. After it was decided that it was a good match, the doctor went back in and permanently attached the liver. When Don’s labs came back after surgery, they learned there was more cancer near the pancreas. He would need surgery to have it removed, a surgery that most hospitals would not perform due to the location of the cancer. Thankfully, the team at Froedtert stepped up to the challenge. A few days after surgery, Don was declared cancer free. “You can tell this is a very cutting edge hospital, and they’re right here in Wisconsin,” Paula said. “You would be surprised by all of the different license plates we see at the hospital. They come from all over the country,” she continued. Both Don and Paula were so thankful for the expertise and support that the team provided through the whole process. This wasn’t Don’s first experience with cancer. He was diagnosed with colorectal cancer in 1998 and after surgery, radiation and chemotherapy was declared cancer free and stayed that way for 18 years. When reflecting on being diagnosed with cancer a second time, Don said “I got through it the first time and I’ll do it again.” In the fall of 2016, the Sipes sold their home in Appleton. They had been renting a house in Milwaukee close to the hospital because of the time they had to spend there. In May of 2017, Don and Paula moved into a renovated barn behind their daughter’s house in Oak Creek, the perfect place to recover. Don is now recovering well. It’s a slow, hard process and can take up to a year for a full recovery. The three months following surgery, Don was required to be in a germ-free zone. This meant he couldn’t be exposed to large groups of people, especially those who were ill, because his immune system was very weak. This was hard for the family because Don had to be isolated during a time when everyone wanted to see how he was doing and be there to support him. After Don returned home from the hospital, a nurse initially came to the house three times a week. Her visits became less frequent as time went on. A lab technician also comes to the house for blood draws twice a week. “It’s all you do and it consumes your life,” Paula explained. “But the care team sure helps you, they have it down to an art.” Don takes about 15 pills per day including antirejection medication. He currently has a whole team of health care professionals taking care of him because the liver affects many other organs and a transplant affects the entire body. Don now has a daily routine in place which helps with his recovery. He gets up in the morning at 8 a.m. and takes his medicine, eats breakfast and takes a nap late in the afternoon. Three times a networkhealth.com
Although an organ donor’s information is kept completely confidential, the donor family and donor recipient are allowed to correspond with each other. At Froedtert, all communication goes through the hospital’s social worker.
WHAT’S THAT? Biliary drains – Tubes inserted into the bile duct to allow bile to drain from the liver
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We didn’t have to hassle with anyone, Rosanne took care of everything. I didn’t have the energy and was overwhelmed. - Paula Sipe
Rosanne Rott, Case Manager at Network Health
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DID YOU KNOW?
week, Paula and Don head to the Wisconsin Athletic Club for water aerobics. Paula attended water aerobics while Don was in the hospital and it was very therapeutic for her, a nice escape for some time to herself. During this critical time in Don’s life, Paula was and still is his primary care giver. She had to set up appointments, make sure he was getting the home medical equipment he needed and keep him on track with his medications. Not to mention, taking care of everyday tasks like paying bills and cooking meals. Life became very overwhelming. The Sipes found out about the care management team at Network Health and called right away. Don was put in touch with case manager, Rosanne Rott. Paula couldn’t be more grateful for the support and expertise that Rosanne provided her. “We didn’t have to hassle with anyone, Rosanne took care of everything. I didn’t have the energy and was overwhelmed,” Paula said. Network Health and Rosanne have been very valuable to Paula as a caregiver. “I was taking care of Don, I just couldn’t deal with insurance and everything else,” Paula said. Rosanne helped Paula arrange Don’s care and took care of everything on the insurance side while providing emotional support for Don and Paula through the entire process. A testament to Don’s successful recovery is that Paula used to know Rosanne’s phone number by heart, but now she needs to look it up if she needs to call her. “She really went above and beyond with calling me and asking how I was doing,” Paula said. “She let me talk, and that means a lot to me.” While Paula really appreciated the extra emotional support Network Health’s care management team provided, Don was grateful for the financial peace of mind. He explains, “If we didn’t have insurance, we would be bankrupt right now, I can’t even imagine what we would do.” Before the transplant, everything the Sipes did was just to keep Don alive. Now they are able to focus on a more complete picture of well-being. “Our goal is to get him recovered so we can enjoy life again,” Paula said.
Interested in becoming an organ donor? Visit donatelifewisconsin.org for more information.
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Treating Common Summer Ailments S
ummer is a great time to get outdoors. Whether you are spending time around the lake or pool, in the woods or just getting outside and being active, it can lead to common summer ailments such as sunburn, bug bites, dehydration and heat rash. Here is a list of some of the most common ailments and how to identify and treat them.
Heatstroke and Dehydration
Heatstroke and dehydration are two major causes of illness in the summertime. Heatstroke symptoms include a change in mental status, confusion, lack of sweating and the skin turns hot and red. Dehydration symptoms include increased thirst, dry mouth, weakness, dizziness, confusion, sluggishness and fainting.
Treatment
Go to a cooled room with air conditioning, drink plenty of water and use ice packs on the neck.
Sunburn
Sunburn is one of the most common summertime injuries, mostly caused by not wearing or reapplying sunscreen. Sunscreen should be reapplied at least every two hours to avoid sunburn. To further reduce the risk for sunburn, avoid or minimize outdoor activities between 10 a.m. and 2 p.m., when the sun is the strongest, and wear a hat and sunglasses. These measures can also reduce the risk of skin cancer.
Treatment
Minor sunburns can be treated with aloe and other soothing lotions, as well as pain relievers. A blistering sunburn may require treatment at an urgent care facility. Blisters could indicate a second- or third-degree sunburn and should receive medical attention to prevent infection.
Bug Bites and Insect Stings
Many insect stings and bites, such as mosquito bites, are mostly just annoying. But in Wisconsin, these insects have been known to transmit certain infectious diseases, such as West Nile disease. Individuals who have suffered mosquito bites and are displaying symptoms such as a fever, should be tested. Bee stings are another worry, especially in people who are allergic to bees, have been stung multiple times or show symptoms of anaphylaxis.
Treatment
A person having a reaction to a bee sting should be treated immediately with Benadryl® and an epinephrine injection. An appointment with a doctor should also be scheduled for those who are allergic to bee stings or are showing signs of anaphylaxis. To relieve mild pain, itching and swelling of a sting or bite, wash the area with soap and water, then apply an ice pack or cold cloth for 15 to 20 minutes once an hour for six hours. You can also use a nonprescription cream or gel with hydrocortisone or lidocaine to relieve the itching, redness and swelling. If you experience difficulty breathing, swelling of the lips, eyelids or throat, dizziness or nausea, seek medical attention right away. By knowing the symptoms and treatments for these common summer ailments, you’ll be better prepared to get the most out of the short Wisconsin summer.
Do You Need Help Submitting a Claim?
M
ost hospitals and doctor offices will submit claims on your behalf. But some out-of-area medical facilities may require that you pay for care at the time it’s given. To arrange for reimbursement, you must send itemized bills and proof of payment within 90 days to Network Health at the address below. For more information, contact our customer service department at the number listed on page two.
Network Health, Attn: Claims Department P.O. Box 568, Menasha, WI 54952 12 | balance • S u m m e r 2 017
networkhealth.com
For a complete list of recent changes to our provider network, go to networkhealth.com/providerchanges.
How Network Health Finds Quality Doctors D
id you know that Network Health has a process of evaluating doctors in order for them to become part of our network? This process is called credentialing and it takes place following the review of an individual practitioner or organization’s qualifications. There is a full-time staff right here in Wisconsin who perform a thorough evaluation of the following. n Professional education n Training n Residency n Licenses n Practice history n Quality of care n Competence n Backgrounds and board certifications n Criminal background checks Providers must re-apply for credentialing with Network Health every three years with monitoring between credentialing cycles. Ongoing monitoring consists of the following. n Patient complaints and negative events and follow up n Lawsuits and settlements and follow up n Criminal history and follow up n License n Malpractice n Board certification
Access and After-Hours Care
Timeliness for medical and behavioral services any of us experience the need for some type of health care in our life whether it’s access to after-hours, urgent, routine or preventive care. Network Health’s Quality Improvement Department works with doctors and hospitals to ensure you’re able to get medical care in a timely manner. You should always be able to get the care you need, so we require our providers to offer access to medical and behavioral health services without excessive scheduling delays. We communicate standards for timeliness of appointments and office waits with our provider network. If you don’t feel your need for urgent, routine or preventive care is being scheduled in a timely manner, please contact us at the number listed on page two. We’re here to help you get the care you need, when you need it.
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I want to make sure our members have the best care. These are families–someone’s son, daughter, brother, sister, mom or dad. Laura Borgens Quality Control Specialist at Network Health
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Be Aware of Scams W
e’ve all heard the phrase, “If it seems too good to be true, it probably is.” Yet, many scam artists have found ways to convince us otherwise, meanwhile stealing our financial and personal information for their benefit. With this in mind, it is important to protect yourself from both financial and insurance fraud. To do so, we recommend you follow these tips to keep your information safe and secure. n Never sign blank insurance claim forms. n Do not do business with door-to-door or telephone sales people who tell you that services of medical equipment are free or available at no direct cost to you. n Only give your insurance identification and Social Security number to those who have provided you with medical services. n Keep accurate records of all your health care appointments and verify your explanation of benefits and all bills for services. n Always watch your credit card and bank statements for improper billing activity or fraudulent withdrawals. n Monitor your credit report regularly. Sometimes, people don’t report scams because they are ashamed or embarrassed. It’s important to understand that it’s not your fault. If you believe you may be a victim of an insurance scam, we are here to assist you. Call us at the number on page two or send an email to paymentintegrity@networkhealth.com.
Take Me Out to the Ball Game As a Network Health member, enjoy a special ticket price for the Wisconsin Timber Rattlers games below.
July 10 at 12:05 p.m. July 24 at 12:05 p.m. August 8 at 7:05 p.m.
August 21 at 12:05 p.m. August 22 at 7:05 p.m.
$14.50/includes box seat ticket, brat or hot dog and beverage
Offer valid in-person only at Neuroscience Field. Just ask for the Network Health ticket at the ticket window. 14 | balance • S u m m e r 2 017
networkhealth.com
1
THE IMPORTANCE OF COMPLETING A
HEALTH RISK ASSESSMENT A
health risk assessment (HRA) asks questions about your health and lifestyle habits. The answers you give are used to create your personal health assessment summary and lifestyle improvement plan. This report identifies your health risks and tells you about healthier habits you can adopt to lessen your risk of health conditions. Surprisingly, most people have no idea what their current health status is. As a result, most people go years without paying attention to the behaviors that can be modified to maintain or improve present health status. The assessment will give you a snapshot of your current health status to identify potential risks that could lead to a more serious and costly health condition.
1.
Go to networkhealth.com, click on the Member Sign In button.
2.
On the My Account screen, enter your User ID and Password.
3.
Click on the WebMDÂŽ link.
4. 5.
Click on the Take It Now button to begin.
2
3
Each question is either a drop down menu, multiple choice or fill-in-the-blank. Answer each question the best you can recall (some questions require an answer and will not let you proceed if left blank).
Use the results from your health risk assessment and work with your doctor to determine what changes you can make.
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life. health. wellness.
Schedule and Track Your Child’s Preventive Screenings
I
t can be tough to keep track of all your child’s recommended screenings and preventive care. Childhood is a time of rapid growth and change. Well-child visits, which consist of a physical exam and general review of health and well-being, are considered preventive, and covered by Network Health at no charge when visiting a doctor in our provider network. Even if your child is healthy, well-child visits are important for their overall wellness and the prevention of future health issues. Keep this chart handy to help you track care as your child receives it. For specific coverage information, refer to your Summary of Benefits document. Call our customer service department at the number listed on page two if you have questions regarding coverage. You can also see a more comprehensive list including preventive services for adults by visiting networkhealth.com/members, select the Resources tab on the right side of the page, click the Learn More button and then choose Preventive Services Guide.
WELL-CHILD VISITS AGE
RECOMMENDATION
DATE RECEIVED
Newborn
1 visit ( 3-5 days after discharge)
0-2 years
1 visit at 2, 4, 6, 9, 12, 15, 18 and 24 months
3-6 years
1 visit at 30 months and 1 visit every year for ages 3-6
7-10 years
1 visit every 1-2 years
11-18 years
1 visit every year
IMMUNIZATIONS VACCINE
RECOMMENDATION
Chickenpox (varicella)
First dose at 12–15 months old; Second dose at 4–6 years old. Adolescents 14 and older with no history of vaccination or disease may receive two doses 4–8 weeks apart.
Diptheria, tetanus, whooping cough (pertussis)
Four doses of DTaP, one at 2, 4, 6 and 18 months old One dose of Tdap between 11 and 12 years with a Td booster every 10 years after. Those older than 7 years and not previously immunized can get a single dose of Tdap.
Flu (influenza)
Two doses 4 weeks apart for healthy children between 6 months and 8 years the first time they get the vaccine. Children who’ve previously had the flu shot can receive one dose annually.
Haemophilus influenza type b
One dose at 2, 4 and 6 months and once between 12–18 months old
Hepatitis A
Two doses at least 6 months apart between 12–23 months old. For children not previously immunized, Two doses can be given at least 6 months apart at your doctor’s discretion.
Hepatitis B
One dose to all newborns before leaving the hospital, a second dose between 1–2 months and a third dose between 6–18 months. May begin between 2–18 years old if not immunized as a baby.
Human papillomavirus (HPV)
Three doses over a 24–week period starting at age 11 for boys and girls. Your doctor may give the vaccine as early as age 9 if your child is at high risk.
Polio
One dose at 2 and 4 months and between 16–18 months (3 doses total). Then, one dose between 4–6 years old.
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DATE RECEIVED
networkhealth.com
IMMUNIZATIONS VACCINE
RECOMMENDATION
Measles, mumps, rubella (MMR)
One dose between 12–15 months and a second between 4–6 years. Can be given to older children if no history of vaccination or the disease.
Meningitis (meningococcal)
One dose between 11–12 years, with another dose at 16 years. If the first dose is done between 13–15 years, then give the second dose between 16– 18 years. Doctors may give vaccine as early as age 2 to children at high risk.
Pneumonia (Pneumococcal)
One dose at 2, 4 and 6 months and again at 12–15 months. Children over age 2 can get a single dose if not previously immunized. Children with underlying medical conditions can receive an additional dose. Children at high risk can be vaccinated after age 7.
Rotavirus
One dose at 2, 4 and 6 months old
Hepatitis B
One dose to all newborns before leaving the hospital, a second dose between 1–2 months and a third dose between 6–18 months. May begin between 2–18 years old if not immunized as a baby.
Human papillomavirus (HPV)
Three doses over a 24–week period starting at age 11 for boys and girls. Your doctor may give the vaccine as early as age 9 if your child is at high risk.
DATE RECEIVED
DOCTOR VISITS AND TESTS ASSESSMENTS, SCREENINGS AND COUNSELING
RECOMMENDATION
Alcohol and drug use assessment
Ages 11–18 during well child visits
Autism screening
At 18 and 24 month well-child visits
Blood pressure
At 0-11 months, 1-4 years, 5-10 years, 11-14 years, 15-17 years
Congenital hypothyroidism
During newborn screening
Cavity prevention
Fluoride application to primary teeth up to age 5 when primary teeth have erupted
Depression screening and behavioral assessments
Ages 12-18 years during well-child visits
Developmental screening
Children under age 3 during well child visits
Dyslipidemia screening
Children at higher risk at 1-4 years, 5-10 years, 11-14 years and 15-17 years
Gonorrhea preventive medication
Once at birth
Hearing loss screening
All newborns and at ages 3, 4, 5, 6, 8, 10, 12, 15 and 18 years
DATE RECEIVED
Height, weight and body Ages 0-11 months, 1-4 years, 5-10 years, 11-14 years, 15-17 years mass percentile Hematocrit or hemoglobin screening
Once at 12 months, once between ages 11–18, and once every year for menstruating adolescents
Hepatitis B screening
Adolescents 13-18 at high risk, frequency dependent on risk
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life. health. wellness. DOCTOR VISITS AND TESTS ASSESSMENTS, SCREENINGS AND COUNSELING HIV screening
RECOMMENDATION Start at age 15. Screening for children under 15, if they’re at high risk. Frequency dependent on risk.
Lead screening
Children at higher risk under age 6, frequency dependent on risk
Medical history
At each well-child visit
DATE RECEIVED
Newborn screenings as identified by the Federal Once at birth following Advisory Committee on Heritable Disorders guidelines Health Resources and Services Administration Obesity screening and physical activity and nutrition counseling
At your doctor’s discretion starting at age 6
Oral health risk assessment
Children 0-11 months, 1-4 years and 5-10 years
Sexually transmitted infection (STI) screening At your doctor’s discretion for all sexually active adolescents and counseling Tobacco–use screening and counseling
School aged children and adolescents during well child visits
Tuberculosis (TB) testing
Children at higher risk ages 0-11 months, 1-4 years, 5-10 years, 11-14 years, 15-17 years
Vision screening
At least once ages 3-5
DRUGS (PRESCRIPTION REQUIRED) PRESCRIPTION
RECOMMENDATION
Iron supplements
Children ages 6–12 months at risk for iron deficiency
Oral fluoride supplements
Children 6 months through age 5 without fluoride in their water source
DATE RECEIVED
Your Input Is More Valuable Than You Know T
hroughout the year, Network Health conducts member surveys because we want to know how you feel about your benefits and your doctors. Surveys gauge our performance and your satisfaction with topics like customer service, benefits and quality measures such as access to care. Network Health conducts some surveys, but often, a third-party survey administrator will conduct the research. This is a best practice in the health insurance industry to help ensure questions are unbiased and results are accurate. Survey results also shape decisions at Network Health. Your feedback helps define which aspects of our business are thriving and identify areas for improvement. Most surveys are issued anonymously and at random, allowing you to provide feedback to Network Health with complete confidentiality. If you receive a mailing or phone call to complete a survey for Network Health, share your experiences and feedback. By doing so, you’ll help us continue to improve and better meet your needs as a member. 18 | balance • S u m m e r 2 017
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Easy Access to the Information You Need H
ave you ever needed to quickly check the status of a health care claim or check your benefit information? Network Health will soon have a new 24-hour self-service option for these types of calls to customer service. When calling Network Health, members will have the option to speak with a customer service representative right away or use a self-service feature. This new feature will allow you to quickly and easily do the following. n Check benefit information such as coverage for a specialist visit n Check on the status of a claim for health care services received It’s okay if you don’t want to use the self-service option. Just press “0” to speak with a live customer service representative at any time during your call. You can also go online to your member portal at networkhealth.com and select Member Sign In in the upper left corner of the screen. The portal is a secure online gateway to information about your plan, benefits, claims and more. You can even compare prescription drug costs, order prescriptions and send a private email to our customer service department to ask a question. If you are signing in the for the first time, make sure you have your member ID card handy.
Join our CoCreate Movement Through our CoCreate movement to build a better health insurance industry, Network Health asks members and consumers what we could do better. Recent CoCreate events have focused on our wellness program and the explanation of benefits (EOB) received after a doctor visit. By working with real customers throughout Wisconsin, we’re able to create a better health insurance experience. If you would like to be a part of the outcome, please contact marketing@networkhealth.com. Visit CoPilotWI.com/CoCreate to see what we’re up to.
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1570 Midway Pl. Menasha, WI 54952
MAILED ON 6/30/17
What’s your your NEXT NEXT Chapter? Chapter? What’s Takeyour yourstory storyininany anydirection directionwith withaaNetwork NetworkHealth HealthMedicare MedicareAdvantage Advantageplan plan Take
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844-277-7174 844-277-7174
VISIT VISIT
NetworkHealthMeetings.com (TTY800-947-3529) 800-947-3529) NetworkHealthMeetings.com (TTY findaaFREE FREEMedicare Medicaremeeting meeting Mondaythrough throughFriday, Friday, totofind Monday in your neighborhood a.m.- -88p.m. p.m. in your neighborhood 88a.m. salesperson personwillwillbebepresent presentwith withinformation informationand andapplications. applications.For Foraccommodations accommodationsofofpersons personswith withspecial specialneeds needsatatsales salesmeetings, meetings,call call800-378800-378A Asales 5234, 8 a.m. to 8 p.m., seven days a week. TTY users should call 800-947-3529. Network Health Medicare Advantage Plans include MSA and PPO 5234, 8 a.m. to 8 p.m., seven days a week. TTY users should call 800-947-3529. Network Health Medicare Advantage Plans include MSA and PPO plans with a Medicare contract. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. You must continue to pay your plans with a Medicare contract. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. You must continue to pay your Medicare Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact Medicare Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact theplan. plan.Limitations, Limitations,copayments copaymentsand andrestrictions restrictionsmay mayapply. apply.Benefits, Benefits,premium premiumand/or and/orcopayments/coinsurance copayments/coinsurancemay maychange changeJanuary January11ofofeach eachyear. year. the Out-of-network/non-contracted providers are under no obligation to treat Network Health members, except in emergency situations. For a decision Out-of-network/non-contracted providers are under no obligation to treat Network Health members, except in emergency situations. For a decision aboutwhether whetherwewewillwillcover coverananout-of-network out-of-networkservice, service,weweencourage encourageyou youororyour yourprovider providertotoask askususforfora apre-service pre-serviceorganization organizationdetermination determination about before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Network Health complies with applicable Federal civil rights laws and does not discriminate cost-sharing that applies to out-of-network services. Network Health complies with applicable Federal civil rights laws and does not discriminate onon thebasis basisofofrace, race,color, color,national nationalorigin, origin,age, age,disability, disability,ororsex. sex.If Ifyou, you,ororsomeone someoneyou’re you’rehelping, helping,has hasquestions questionsabout aboutNetwork NetworkHealth, Health,you youhave havethe the the right to get help and information in your language at no cost. To talk to an interpreter, call 800-378-5234. Si usted, o alguien a quien usted está right to get help and information in your language at no cost. To talk to an interpreter, call 800-378-5234. Si usted, o alguien a quien usted está ayudando,tiene tienepreguntas preguntasacerca acercadedeNetwork NetworkHealth, Health,tiene tienederecho derechoa aobtener obtenerayuda ayudae einformación informaciónenensusuidioma idiomasinsincosto costoalguno. alguno.Para Parahablar hablarcon con ayudando, un intérprete, llame al 800-378-5234. Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Network Health, koj muaj cai kom lawv un intérprete, llame al 800-378-5234. Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Network Health, koj muaj cai kom lawv muabcov covntshiab ntshiabluslusqhia qhiauas uastau taumuab muabsau sauuauakojkojhom homlusluspub pubdawb dawbrau raukoj. koj.Yog Yogkojkojxav xavnrog nrogibibtug tugneeg neegtxhais txhaisluslustham, tham,huhurau rau800-378-5234. 800-378-5234. muab Y0108_1040_033117 Accepted 04142017 Y0108_1040_033117 Accepted 04142017