The Role of HMOs and PPOs in Health Insurance

Posted by on Dec 11, 2014 in Healthcare Industry | Comments Off

Health Management Organizations (HMOs) and Preferred Provider Organizations (PPOs) are insurance companies that offer health insurance policies that are limited to certain “member” or “accredited” health service providers. They don’t actually have their own doctor, hospitals, or pharmacies but instead have a contract with a network of these third parties to provide the services that are included in the insured’s policy.

For example, if a policyholder of HMO A needs surgery for a covered condition, the policyholder obtains a letter of authorization to have the surgery done at an accredited hospital by an accredited surgeon and anesthesiologist. Depending on the policy, the patient pays nothing or only a certain percentage (co-pay) of the total cost. HMO A will take care of the balance by paying the service provider directly.

That sounds simple enough, but like mentioned earlier, HMOs and PPOs are insurance companies, and like most of its brethren, they typically have a trifecta to minimize their financial exposure: deny, defend, and delay. Because an HMO or PPO policyholder does not make a direct claim with the insurance company, they are unaware of this, but the service providers know it only too well. While in most cases a pre-approved treatment cannot be denied, the HMO or PPO can certainly delay payments, and this is the practice that the Texas Prompt Pay Act addresses.

The practice of insurers to delay payment is certainly not restricted to Texas, but the TPPA is exclusive to contracted health service providers in the state. In a nutshell, the state says insurance companies that delay payment to service providers beyond a certain number of days after a clean claim will be subject to substantial penalties and interest charges. A service provider that has accumulated a sufficient number of unpaid claims may find it worth their while to retain a Texas prompt pay attorney to compel the insurer to pay what is due. In most successful cases, the plaintiff may be entitled to be reimbursed for reasonable lawyer fees by the defendant, so it’s a win-win situation.

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Employment Laws Enforced by the EEOC for the Benefit of Employees

Posted by on Oct 31, 2013 in Employment Law | Comments Off

Employment discrimination laws are intended to promote the rights of all individuals to equal and fair employment opportunities, as well as to establish balance and order in the workplace by stating what practices are permitted and not permitted by law. There are more than half a dozen state and federal laws passed to protect employee rights; any act of discrimination could be a direct violation of these laws.

The enforcement of these laws is the task of the U.S. Equal Employment Opportunity Commission of 1964 (EEOC), an independent regulatory body that was created by the US Congress on July 2, 1964, for the specific purpose of implementing Title VII of the Civil Rights Act of 1964. These laws include:

  • Title VII of the Civil Rights Act of 1964: prohibits any form of discrimination based on color, race, national origin, religion and sex. This law also considers illegal any act of retaliation against a person due to his/her decision to: take part in an investigation or lawsuit; file a discrimination charge; or, even just complain about discrimination. Religious practices, so long as these will not slow down business operations, are also protected by this law too.
  • The Equal Pay Act of 1963 (EPA): this law stipulates that individuals, regardless of gender, should receive the same wage so long as the work they perform is equal (requiring the same efforts, skills and responsibility)  and performed in the same workplace.
  • The Age Discrimination in Employment Act of 1967 (ADEA): individuals aged 40 and above, who apply for job or who are already employed, are protected by this law.
  • The Pregnancy Discrimination Act: this law is one of the amendments made on Title VII of the Civil Rights Act; it makes discrimination against women due to pregnancy or childbirth (as well as any medical situation akin to pregnancy and childbirth) illegal.
  • The Genetic Information Nondiscrimination Act of 2008 (GINA): this law took effect on November 21, 2009. It renders unlawful any act of discrimination due to genetic information, which includes disclosure of information regarding his/her or his/her family’s genetic tests, disease medical condition or disorder (mental, physical or emotional)
  • Title I of the Americans with Disabilities Act of 1990 (ADA): discrimination against people with disability despite their being qualified to the work/position they have applied for is illegal.
  • Sections 102 and 103 of the Civil Rights Act of 1991: these laws are actually improvements of ADA and Title VII. They “permit jury trials and compensatory and punitive damage awards in intentional discrimination cases.” (
  • Sections 501 and 505 of the Rehabilitation Act of 1973: this law strictly prohibits discrimination of people with disabilities and who are employed in the federal government.

Any discriminatory bias, whether obvious or not, in hiring an applicant or firing, promoting, training, assigning particular work and awarding fringe benefits or high wages is likewise an unjust employment practice and is, therefore, unlawful.

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What is RU-486?

Posted by on Oct 4, 2013 in Abortion | Comments Off

The subject of abortion is always a sensitive one, even in countries like the US where the right to terminate a pregnancy within a certain time period had been established by the Supreme Court as constitutional under the 14th Amendment’s right to privacy under the due process clause. The controversy regarding abortion continues to be rife, and among the issues that come up for debate is the method used to terminate a pregnancy, such as medical abortion using mifepristone with prostaglandin, a formulation classified by its maker Roussel Uclaf as RU-38486 or simply RU-486. Mifepristone is an antiprogestin, a synthetic compound that’s suppresses the action of progesterone, a hormone that plays an important role in menstruation and pregnancy.

RU-486 was given Subsection H approval in the US by the Food and Drug Administration (FDA) under the trade name Mifeprex in September 2000 for pregnancy termination in the first 7 weeks of the pregnancy. Medical abortion is considered more effective than surgical abortion, being less likely to fail to complete the abortion during the first 7 week of pregnancy, and the use of Mifeprex is considered the most effective of medical abortion methods. Mifeprex is a prescription drug that is only available via physicians who are specially qualified. Because Mifeprex carries the risk of excessive bleeding or incomplete abortion, the prescribing physician must have the skills to administer a blood transfusion or perform an emergency surgical abortion. Mifeprex is available in Washington, D.C., Puerto Rico, Guam, and all 50 states and is currently used in a majority of first trimester medical abortions.

The main issue against Mifeprex even among pro-choice groups is that there is too little emphasis placed on the risks associated with its use. Most women do not realize that it is not simply a matter of popping a pill, but that it is a painful process that can last as much as 12 days. Even then, there is a risk of abortion failure as well as other effects that are detrimental to the mother’s health.

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NFL Settles with Retirees over Head Injuries

Posted by on Sep 3, 2013 in Brain Injuries, Personal Injury | Comments Off

After months of mediation, retired football players are finally getting some compensation for the effects of head injuries they sustained during their professional stint.

The settlement came as a surprise just before the 2013 football season, but may have been driven by the negative publicity the issue has had on the sport. The lawsuit was brought by 4,500 former players who claimed injuries sustained from concussions received during their run in the league.

It took 9 weeks of mediation, but a figure of $765 million was agreed upon to cover needed medical care, compensation for injuries, legal expenses and medical research. Included in the lawsuit were 10 Hall of Famers, including the families of Junior Seau and Ray Easterling.  Both players committed suicide due to mental and cognitive problems sustained from concussion-related events.  The individual lawsuits, which were consolidated in Philadelphia, initially asked for a total of $2 billion in compensations.

As part of the settlement, the NFL admits to no wrongdoing or liability. Any of the plaintiffs may challenge or opt out of the settlement, and any player who can prove impairment due to concussions received during their football career is eligible to receive compensation. The settlement in no way bars players from filing lawsuits against the NFL in the future, although they would have to be handled through the union’s arbitration process.

The settlement ensures that at least some players with recognized cognitive and neurological disorders such as Parkinson’s, Alzheimer’s, dementia, or Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease) can get immediate medical treatment and care.

The settlement will be disbursed in stages. It should be easy for the NFL to come up with the funds; the projected earnings for 2013 is in excess of $10 Billion.

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Los Tipos Mas Comúnes de la Negligencia Médica

Posted by on Jul 25, 2013 in Medical Malpractice, Personal Injury | Comments Off

En los Estados Unidos, la negligencia médica es una problema muy serio. Si un medico haga un error en el tratamiento de un paciente, las consecuencias podrían ser muy graves. Además de los lesiones fisicos, las victimas de la negligencia médica frecuentemente tienen que ocuparse con las cuentas medicas y el perdido de los ingresos. Por lo tanto, los medicos son responsables de las consecuencias de la negligencia médica.

Hay muchos tipos de errores que pueden ser considerado como la negligencia médica. Sin embargo, cualquier tipo de error que resulta en el padecimiento de un paciente, grande o pequeño, puede resultar en demanda para las costas.

Cinco Tipos Comúnes de la Negligencia Médica

Los siguientes cinco tipos de la negligencia médica son algunos de los mas comúnes en los Estados Unidos:

  1. Los errores quirúrgicos
  2. Falta del diagnostico
  3. Los diagnosticos erroneos
  4. Los errores de prescripciónes
  5. Los lesiones en el nacimiento

Todos estos errores pueden tener consecuencias muy dañinas para las pacientes y sus familias, y los medicos quien causan a estos errores tienen la responsabilidad de pagar las costas de las consecuencias de sus acciones. Con la representacion de un abogado experimentado, las victimas de la negligence médica pueden obtener la justicia que merecen.

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Birth Defects from Depakote Use

Posted by on Jul 23, 2013 in Defective Pharmaceuticals | Comments Off

People who suffer from seizures, bipolar disorders, migraine headaches, or epilepsy are often prescribed the medication Depakote. It is a prescription that has been approved by the FDA as safe for use, although it has been labeled as “Pregnancy Category D”, indicating that is has significant evidence of human fetal risks based on adverse reactions from investigational and marketing studies in humans. Using Depakote during the first trimester of pregnancy increases the risk of the child having skull or skeletal birth defects.

A number of craniofacial defects (malformed skull and face) can affect the fetus and, although there are some that can be treated, many are still life-threatening. Among the most dangerous and critical are:

  • Craniosynostosis – a head and skull defect where the joints connecting the bones of the skulls are prematurely fused causing abnormal brain growth, pressure in the brain, facial deformities, and an abnormally-shaped head.
  • Microcephaly – a condition where the child is born with an abnormally small skull size, which can eventually cause mental development issues in the long run.
  • Encephalocele – a condition where the skull does not fully develop, causing parts of the brain to push through some of the opening. Although there are surgeries to help fix the skull and push back the brain, the already inflicted brain damage is usually permanent.
  • Anencephaly – a very serious defect, a child is born without parts of the brain, skull or scalp. The children born with this condition often suffer from blindness, deafness, and are unable to feel pain. Most often, they are stillborn or die soon after birth.

Mothers who are pregnant or are planning to get pregnant should stop taking Depakote. The website of Williams Kherkher advises that it would be better to find another prescription to help in managing epilepsy or mental health disorders. Although the conditions brought up as a result of this pharmaceutical defect can be treated through surgery, the financial and emotional stress can be difficult to deal with. Compensation can be given to the family of the victim, but that does not change that the baby’s health and future have been compromised.

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An Overview of Dog Bite Injuries

Posted by on Jul 22, 2013 in Dog Bites, Personal Injury | Comments Off

Dog bites are among the rising causes of emergency room visits. With the popularity of television dog shows and dog contests, there are a big increase in the number of people getting dogs for pets, and sadly many of these owners who acquire dogs are not aware of how to properly care for them of understand the dog’s needs. Also, many dog owners get aggressive dogs but fail to train them properly, causing a number of dog bite injuries to innocent people.

One of the dangers of dogs bites are infections, and it occurs when the dog’s teeth punctures the skin of the victim. This wound can then be open to bacteria from the dog’s saliva. Not getting immediate treatment for the wound or failing to properly clean the wound can lead to infections. It is generally these infections that make dog bites serious and life-threatening.

As the majority of victims of dog bites are male children from the ages of five to nine, it is vital that treatment is immediately given once the injury is determined. It is always important to understand that in any dog bite, an infection is very likely to happen. After the initial first aid treatment, check for any swelling, inflammation or redness around the area of the injury. If there is increased warmth in the area or pus or white discharge is visible, then it is infected. Another sign is having red streaks that are radiating from the dog bite.

Based on an article from the website of Levinson Axelrod, P.A., dog bite injuries can be minor or severe depending on the injury itself, however, once there has infection the health of the victim is already compromised. Once there is a deep wound, infections such as meningitis, rabies, tetanus, and others should be checked. Injections to prevent these infections are necessary in order to protect the victim. Once an infection is observed but not attended immediately, it can lead to limb amputation or worse, death. Make sure the dog bite wound is cleaned thoroughly, bandaged, and have a doctor take a look at it just to be sure.

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Being Aware of Sexual Harassment

Posted by on Jul 20, 2013 in Sexual Harassment | Comments Off

Professionalism is the law in a work environment; therefore any inappropriate actions or words can be a bit complicated and hard to cope with. Sexual harassment in the work place can happen to anyone, regardless of position, age, and gender. It is a type of discrimination based on sex, undermining the person’s sense of personal dignity. If not addressed immediately, it can intensify into something more damaging.

There are generally two forms of sexual harassment: quid pro quo (or this for that, something for something), and hostile work environment. Quid pro quo means that an employee’s employment, promotions, decisions, and general conditions rely on how much they are willing to provide sexual favors. Hostile work environment is the more common form (albeit harder to pinpoint), often manifesting as having an “uncomfortable” work environment due to sexually-charged demeanors and/or statements.

Sexual harassment can be obvious, but other times it is subtle and hard to determine. It is only later that the victim feels humiliated or harassed. Recognizing acts of sexual harassment in the workplace is one of the things that can help protect you from being a victim. As reported on the website of Ritter & Associates, the most common things to look out for are:

  • Requests of sexual favors (often from someone of higher position in the company), including having sex and/or going out on a date to another employee.
  • Inappropriate physical contact, especially in a sexually provocative manner.
  • Forwarding literature and/or pictures that is of sexually specific or provocative in nature. They can be sexual jokes, intimate personal pictures and others.
  • Statements or remarks of another person’s physical appearance and/or genitalia that is sexual in nature.
  • Giving or leaving gifts or items that are sexually suggestive.

Once you feel that you are becoming a victim of sexual harassment in the workplace, it should not be ignored or brushed aside. Employees should report that acts or harassment to a higher authority in order for it to stop. One thing that can be done is writing a formal letter of complaint indicating the details of the offense. Know who to send the report to. Anyone who has been targeted for sexual harassment has the right to inform the offending person about their actions (either verbally or in writing) to let them know that their actions are unwelcome, offensive and should stop.

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Look out for Phone Crammers

Posted by on Jul 18, 2013 in Consumer Fraud | Comments Off

In these trying times living life everyday can be hard, especially for those who live their life on a tight budget. Monthly expenses such as mortgage, water, electricity and phone bills need to be monitored in order to avoid any unnecessary payments or over-payments. There are instances where companies charge consumers through fraudulent activities. One of the rising menaces when it comes to consumer fraud is “phone cramming”, an illegal practice which robs people a big amount of money every year.

Phone cramming is a form of consumer fraud where a third-party company charges you on miscellaneous services that you have not agreed to buy or purchase. Often, the charges appear on your phone bill, falsely claiming to your phone company that you have authorized the purchase, and they may appear just once or as recurring charges. This is the main reason why it is always best to look closely at your phone bills before paying.

There are many ways a company can charge you, and there is no one type of cramming charge. Things to look out for are charges such as “member fees, voice mails, web hosting, or activation.” They can charge for just about anything, such as:

  • Collect calls or long distance services
  • Entertainment services (with a 900 or 800 area code)
  • Club memberships or subscriptions on internet-related services
  • Access to restricted websites

It may be difficult to check your telephone billing statement since they are often complicated and makes it harder to detect any phone cramming. One more complicated thing is that once phone cramming has been spotted, consumers don’t know who to turn to. Fortunately, the Federal Communications Commission (FCC) are doing their best to protect consumers from such scams, taking initiatives as to make the billing statement simpler and easy to understand and make the third-party companies contact numbers indicated on the bill for easy communication. If you have fallen prey to such a scam, a personal injury lawyer may be able to help you fight for justice.

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Appreciating the Significance of Nursing Home Injuries

Posted by on Jul 13, 2013 in Nursing Home Abuse, Personal Injury | Comments Off

Many of the elderly residents in a nursing home are subject to some degree of injury for a variety of reasons: absentmindedness, refusal to be assisted, mental problems, or simply physical frailty. Up to a certain point, these nursing home injuries are to be expected and perfectly reasonable.

However, there are some nursing home injuries or signs of neglect which are not acceptable because an elderly resident is dependent on nursing home staff for his or her safety and health. Crowe & Mulvey, LLP,  point out that there is an implicit trust, or duty of care placed on the health professionals in nursing homes. When this trust is breached, it could be the basis for a personal injury lawsuit. Below are examples of unacceptable nursing home injuries that should be stopped.

Loss of weight. While weight loss is not normally considered an injury, in the elderly this is usually a sign of malnutrition. For a person who is already in a fragile state of physical health, not getting enough or getting the wrong kind of nutrition can lead to serious health problems. Nursing home staff should be able to catch signs of malnutrition in their residents before it becomes a problem. If they don’t, it is a clear example of neglect.

Excessive bruising. Bruises are a sign of some trauma to the soft tissue, which could mean as a result of being hit by or falling on a hard object. Occasional nursing home injuries such as bruises are to be expected, but when there are a lot of them or they appear frequently, the cause needs to be investigated immediately. It may be due to physical cruelty by a nursing home staff member or another resident, or it could be a sign of sexual abuse.

Frequent falls. While the elderly are often shaky on their feet, allowing them to fall all the time is tantamount to negligence on the part of nursing home staff. Their duty of care dictates that they should prevent frequent falls, even if they result in noting more than minor nursing home injuries. For elderly people, this can have serious consequences.

Bed sores. A good sign that a resident is being neglected is the development of pressure or bed sores, also referred to as decubitous ulcers. It means that the resident has been allowed to lie for long periods in one position, and can also indicate malnutrition. Bed sores are painful, and in some cases can be severe enough to show bone. This type of neglectful behavior is not acceptable in nursing homes.

Excessive restraints. Sometimes elderly residents can act out and be violent as a result of some mental or physical disorder, and it is necessary to use pharmaceutical or physical restraints. This prevents them from hurting themselves and others. But when it becomes a method of control even when the resident is not aggressive, or the restraints are excessive enough to cause nursing home injuries, then this is abuse.

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