Friday 13 January 2012

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On Dec 7, 2011, Aetna filed a lawsuit against two PPO surgeons and one out-of-network (OON) hospital, in the District Court, Harris County, Texas. Aetna lawsuit seeks to recover damages and attorneys’ fees and for court temporary injunction to stop the OON hospital’s UCR billing and PPO surgeon’s referrals, alleging breach of contract, conspiracy to overcharge, tortious interference, and common law fraud, including “a bill for $99,750 for the removal of ear wax”. A new 2012 “UCR war” already unfolds in the court. ERISAclaim.com offers private Webinars to examine this court case, its profound impacts on all OON providers, and explore compliant solutions and protections under ERISA and PPACA as well as OIG Guidance.

Aetna OON UCR Case info: AETNA HEALTH INC vs. SOFOLA, IFEOLUMIPO O (MD) (Case #: 2011-73949 / Court 152)

In 2012, most out-of-network (OON) doctors, surgical centers and hospitals will “make it or break it”, depending upon the outcome of this new Aetna lawsuit, as an emerging trend in managed litigations.

“While the alleged $99,750 ear wax UCR fee may or may not be an isolated inadvertent error, the payor’s new lawsuit to outlaw all OON UCR billing as fraud certainly represents a new 2012 trend and detrimental blow to all OON providers and 77% of insured Americans in private industry,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

“Failure to recognize the impact of the payor UCR legal actions under $99,750 ear wax anti-fraud strategies and to quickly act with compliant solutions, the OON market will most likely fail by the end of 2012,” warned Dr. Zhou.

According to the court documents, “Plaintiffs Aetna Health Inc. and Aetna Life Insurance Company (collectively, “Aetna”) bring this action under the laws of this state against Defendants Ifeolumipo O. Sofola, M.D. (“Dr. Sofola”), Navin Subramanian, M.D. (“Dr. Subramanian”), and Humble Surgical Hospital, LLC (“HSH LLC”), for breach of contract, unlawful and excessive fees, and to recover damages and reasonable attorneys’ fees for injuries Aetna suffered as a result of the Defendants’ scheme to steer patients to Humble Surgical Hospital (“HSH”), a “non-participating” surgical hospital owned or leased by HSH LLC in which Drs. Sofola and Subramanian through their membership in HSH LLC had a financial interest. HSH in turn sought and received excessive fees from Aetna and its members, charging fees far higher than the reasonable charges for the same services in the relevant market.”

In particular, Aetna alleges self-referrals, cost sharing waiver fraud, non-disclosure of OON referral and UCR billing as deceptive practice to drive up the cost of health insurance:

“The self referral of an insured patient by a ‘participating’ physician to a ‘non-participating’ facility to gain direct and indirect financial benefit from the excessive fees charged by the ‘non-participating’ facility is a wrongful practice resulting in the unjust enrichment of both the referring physician and the facility,” according to the complaint.

“To encourage patients to use HSH rather than a ‘participating’ hospital, the HSH staff has on occasion assured patients that they will only owe the remaining portion of any ‘in-network’ deductible or will otherwise not be subject to higher out-of-pocket costs,” the complaint states.

“After admission, HSH submits excessive fee requests to Aetna, such as a bill for $99,750 for the removal of ear wax, that it would not be able to submit were it a ‘participating’ or ‘in-network’ hospital.”

“Even when the patient is reassured that HSH will not attempt to collect more from the patient than the out-of-pocket coinsurance, deductible or other patient-responsibility charges that the patient would incur were HSH an in-network hospital, both Aetna and the patient are deceived”.

Read News Springhill Group Florida Home Care Online Free | Living & Lifestyle | YUDU

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Guns don’t kill people; people kill people; and people with guns kill even more people.

They also save more people who would otherwise be at the mercy of the criminals.

SPRINGHILL TOWNSHIP, Pa. — An 85-year-old great-grandmother in Fayette County busted a would-be burglar by pulling a gun, then forcing him to call for help while she kept him in her sights.

http://www.thepittsburghchannel.com/news/17232825/detail.htm…

Venus Ramey, 82, confronted a man on her farm in south-central Kentucky last week after she saw her dog run into a storage building where thieves had previously made off with old farm equipment.

Ramey said the man told her he would leave. “I said, ‘Oh, no you won’t,’ and I shot their tires so they couldn’t leave,” Ramey said.

She had to balance on her walker as she pulled out a snub-nosed .38-caliber handgun.

“I didn’t even think twice. I just went and did it,” she said. “If they’d even dared come close to me, they’d be 6 feet under by now.”

http://www.foxnews.com/story/0,2933,267540,00.html

Hancock County Sheriff’s Investigator Andre Fizer said about an 84-year-old man’s decision to shoot through a house door at another man who was trying to barge into the house: “You could tell he was devastated. You could tell he was scared.” And rightfully so. Twenty-year-old Wade Ledesma made repeated attempts to break in to the house at about 5 a.m. on July 27, threatening to kill him throughout.

Ledesma “tried to break through the front door and also tried to enter through a back door and a rear window of the residence. The resident called 911 and reported that the intruder was trying to force his way into the home…. [The elderly man] held himself against the door to keep [Ledesma] from entering,” reported the Sun Herald.

The resident became tired from holding the door and, worded about his and his wife’s safety, asked his wife to get his pistol. He fired a shot through the door, meant to merely be a warning shot, and he hit Ledesma in the leg.

http://www.accessmylibrary.com/coms2/summary_0286-35461877_I…

And those are just the obvious cases.

A few years ago I was at a talk by a Jewish man from Poland who survived WWII because he was able to escape his home before the Nazis rounded them up and was able to get a gun from a family friend. He said that without a weapon he would not have been able to join the partisans and remain safe. He also would not have survived his first night home after the war as some of his “neighbors” knocked on the door in the middle of the night to “invite” him to join them for a party to celebrate his return. He had his rifle with him and leveled at the men during the conversation as he explained to them that he was tired and would prefer staying home…They didn’t press the matter. But he left the next day and never returned. He heard a few days later that a friend of his was not so prepared and was killed by the “neighbors”.

The movie “Defiance” is yet another reminder to Jews that weapons are not something to fear, but to have handy.

Finally…

In 1928, five years before the rise of Hitler, Germany’s freely elected government enacted a “Law on Firearms and Ammunition.” This law required anyone who owned a firearm, or who wanted to own a firearm, to make themselves known to the authorities. Anyone who wanted to purchase a firearm had to get a “Firearms Acquisition Permit.” If you needed ammunition, you had to get an “Ammunition Acquisition Permit.” When you wanted to go hunting, you had to get an “Annual Hunting Permit.” Every firearm that changed hands professionally had to have a serial number and the maker’s or dealers name stamped into the metal. “Proof of need” was made a condition for issuance of all licenses, not just the carry permit. Mandatory prison sentences were imposed on anyone who professionally sold or transferred a firearm or ammunition without a license. Truncheons and stabbing weapons were subject to the same licensing requirements as firearms, in terms of their manufacture and sale.

As a result of the 1928 Law, all firearms and firearms owners were registered. To take firearms from anyone they distrusted, the Nazis simply did not renew permits. Under the law, their privately created law, the Nazis could now easily confiscate all firearms and ammunition from any, or all, selected groups. The gun law of 1928 had served the Nazis well. It made almost all law abiding firearms owners known to the authorities. The 1928 law on firearms and ammunition helped the Nazis to destroy democracy in Germany, by disarming the law abiding majority, whom they feared.

http://famguardian.org/Subjects/GunControl/Articles/NaziGunL…

A right to bear arms is the fundamental right of every law-abiding person to acquire the means to protect themselves even from their own government. One of the first things a government does when it wants to control its citizenry is to control their access to the weapons they need to defend themselves.

Springhill CareGroup on Blogspot

http://springcaregroup.blogspot.com/


Springhill Group Care – Providing for all levels of care, balanced with impressive facilities and exceptional staff. …golden age living and health care at its very best…   At Springhill Care Group, our attitude is to exceed the expectations of our residents and their friends, that offer balanced with impressive facilities and exceptional staff.   At Springhill Care Group, we firmly believe in safeguarding the interests of our clients and we pride ourselves on offering the most resident friendly environment

About Us

Springhill Group look to cater to the special requirements of each person citizen and any changing circumstances that occur throughout their time living in our care. This gives families the comfort that their loved one has the support and care.

We fully understand a need to a place that residents will be proud to call their home is what they require most. All are built in attractive locations, nestled amongst existing communities, so our residents can easily retain their ties with their families.

Springhill Care offers retirees the finest in clinical care, while receiving the positive aspects of living in our cozy and comfortable community.

Email us now at info@springhillcaregroup.net

News- Springhill Group Florida Home Care

http://news.springhillcaregroup.net/



Guns don’t kill people; people kill people; and people with guns kill even more people.

They also save more people who would otherwise be at the mercy of the criminals.

SPRINGHILL TOWNSHIP, Pa. — An 85-year-old great-grandmother in Fayette County busted a would-be burglar by pulling a gun, then forcing him to call for help while she kept him in her sights.

http://www.thepittsburghchannel.com/news/17232825/detail.htm…

Venus Ramey, 82, confronted a man on her farm in south-central Kentucky last week after she saw her dog run into a storage building where thieves had previously made off with old farm equipment.

Ramey said the man told her he would leave. “I said, ‘Oh, no you won’t,’ and I shot their tires so they couldn’t leave,” Ramey said.

She had to balance on her walker as she pulled out a snub-nosed .38-caliber handgun.

“I didn’t even think twice. I just went and did it,” she said. “If they’d even dared come close to me, they’d be 6 feet under by now.”

http://www.foxnews.com/story/0,2933,267540,00.html

Hancock County Sheriff’s Investigator Andre Fizer said about an 84-year-old man’s decision to shoot through a house door at another man who was trying to barge into the house: “You could tell he was devastated. You could tell he was scared.” And rightfully so. Twenty-year-old Wade Ledesma made repeated attempts to break in to the house at about 5 a.m. on July 27, threatening to kill him throughout.

Ledesma “tried to break through the front door and also tried to enter through a back door and a rear window of the residence. The resident called 911 and reported that the intruder was trying to force his way into the home…. [The elderly man] held himself against the door to keep [Ledesma] from entering,” reported the Sun Herald.

The resident became tired from holding the door and, worded about his and his wife’s safety, asked his wife to get his pistol. He fired a shot through the door, meant to merely be a warning shot, and he hit Ledesma in the leg.

http://www.accessmylibrary.com/coms2/summary_0286-35461877_I…

And those are just the obvious cases.

A few years ago I was at a talk by a Jewish man from Poland who survived WWII because he was able to escape his home before the Nazis rounded them up and was able to get a gun from a family friend. He said that without a weapon he would not have been able to join the partisans and remain safe. He also would not have survived his first night home after the war as some of his “neighbors” knocked on the door in the middle of the night to “invite” him to join them for a party to celebrate his return. He had his rifle with him and leveled at the men during the conversation as he explained to them that he was tired and would prefer staying home…They didn’t press the matter. But he left the next day and never returned. He heard a few days later that a friend of his was not so prepared and was killed by the “neighbors”.

The movie “Defiance” is yet another reminder to Jews that weapons are not something to fear, but to have handy.

Springhill Group Florida – Home Care

http://springhillcaregroup.net/


Springhill Group Care – Providing for all levels of care, balanced with impressive facilities and exceptional staff. …golden age living and health care at its very best…   At Springhill Care Group, our attitude is to exceed the expectations of our residents and their friends, that offer balanced with impressive facilities and exceptional staff.   At Springhill Care Group, we firmly believe in safeguarding the interests of our clients and we pride ourselves on offering the most resident friendly environment



ABOUT US

Springhill Group look to cater to the special requirements of each person citizen and any changing circumstances that occur throughout their time living in our care. This gives families the comfort that their loved one has the support and care.
We fully understand a need to a place that residents will be proud to call their home is what they require most. All are built in attractive locations, nestled amongst existing communities, so our residents can easily retain their ties with their families.

Springhill Care offers retirees the finest in clinical care, while receiving the positive aspects of living in our cozy and comfortable community.

Email us now at info@springhillcaregroup.net

LIVING AND CARE OPTIONS

Springhill Group living and care options are available depending on what the residents need and prefer.

Independent Living

The independent accommodations are occupied for those who wish to maintain a significant standard of flexibility, but also value the friendly relationship, the security, recreational facilities, and care that is provided by to them.

The homes are designed to allow residents simple and easy household management encircled by warm and friendly neighbours

Assisted Living

Assisted Living is desirable to people who need a little extra care with their everyday living. You will also find here theflexibility and security of owning your personal space, to have your valuable possessions and things around you.

Resthome Level Care

Resthome level care in a Ryman Village, offers residents the very best in clinical care, while receiving the benefits of living in our warm and welcoming community.