Archive for the ‘Uncategorized’ Category

U.S. To Make More Drugs Easily Available, Cutting Role Docs Play

Wednesday, July 18th, 2018

Americans may soon be able to get cholesterol-lowering medications and other widely used prescription drugs without seeing a doctor, a first step in what could amount to sweeping changes to how patients access treatments for chronic conditions…………….

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GROWDEN v. GOOD SHEPHERD HEALTH SYSTEM

Wednesday, July 18th, 2018

$25,308 Emergency Room Visit

Hospital sued for egregious pricing…………hospital responds by waiving all charges………Judge dismisses lawsuit…………Plaintiff appeals and wants to continue the lawsuit………….Appellate court agrees……..lawsuit continues……………..What is reasonable value of the treatment? Stay tuned……..

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HealthSmart® Launches SmartDecision™ Reference Based Pricing Solution

Wednesday, July 18th, 2018

The Reference Based Pricing movement is unstoppable. More vendors are entering the arena, moving away from managed care networks. HealthSmart is the newest entrant…………….

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Insurance Consultant Faces Sentencing

Monday, July 16th, 2018

William O. Haff

After more than three years in limbo, William O. Haff will learn his fate today before a Federal Judge.

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HHC Group

Monday, July 16th, 2018

As part of its broad suite of cost-containment services, HHC Group provides Medical Necessity (Bill) Reviews (MNRs) for Group Health, Auto and Workers Comp claims. Our Board certified physician specialists review medical records and billed codes to ascertain whether the services and supplies are appropriate and essential. They base their determinations on CMS and other nationally published and recognized guidelines (FDA, AMA, MCG, Cancer Institute, etc.). We do MNRs for all types of claims; prospective, post-service/prepayment and post-payment.

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Hospitals Don’t Mind Being Overpaid So They Are Not Complaining

Monday, July 16th, 2018

David Belk is at it again. Someone please send David a Schuessler Stick ( The Schuessler Stick™)

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In Health Care The Law of Supply & Demand Doesn’t Exist

Sunday, July 15th, 2018

The law of supply and demand doesn’t apply to health care. Lower demand means higher cost.

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I Will Show You How To Cut Your Rx Costs by 50%

Saturday, July 14th, 2018
I’m talking perception vs. reality on our next Expert Session, 7/17. The Pharma industry lobbies for big box PBMs and if you think you’re in good hands, consider this your wake up call…………….

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The Ever Outrageous Outlier

Friday, July 13th, 2018

This one (lawsuit) appears to be all about outlier provisions, and what happens when a really high dollar claim hits a plan………………………………..

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Paychex Now a ‘Top 20’ Insurance Agency in the U.S.

Friday, July 13th, 2018

Paychex ranks as one of the fastest-growing firms in the nation…………………….

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A New Twist in Reference Based Pricing Lawsuits?

Thursday, July 12th, 2018

“And the verdict is…………….”

This case is instructive for employers who use reference pricing.  It is a good reminder that employers who use reference pricing should confirm that they fall within the guidance for establishing a network and confirm that their administrators are correctly explaining the plan terms to providers who call to determine coverage.

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Mike Dendy Announces Launch of AHPA

Thursday, July 12th, 2018

I’m pleased to announce the launch of Association Health Plans of America (AHPA).  AHPA will be sponsored by Job Creators Network (JCN) an Association started by Home Depot founder Bernie Marcus to assist small businesses.  JCN has partnered with Dr. Tom Price former Secretary of HHS and the primary author of the AHP regulations and legendary business and sports legend Fran Tarkenton for the development and national deployment of an AHP targeting small employers and using the new regulations to place the group(s) upon an ERISA self-funded platform.

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Health Care Expert Poses Interesting Question

Thursday, July 12th, 2018

By Mel Schlesinger

Editor: Another interesting observation by Mel Schlesinger: Lower your health care costs by enrolling for a 3 credit hour course at your local college………………………………

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New Cost Containment Strategy? – DIVORCE

Thursday, July 12th, 2018

The following article is another example of a broken health care system and the lengths some take to find affordable health care…………………..

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TPA Sues Teladoc

Thursday, July 12th, 2018

An Illinois benefits administrator is suing the telemedicine company Teladoc for $450,000 in overcharges, claiming the company tried to restructure a refund to avoid a negative outlook on its financial statements.

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One Phone Call Later And Presto – Lower Rx Prices for All Americans

Wednesday, July 11th, 2018

“Just talked with Pfizer CEO and @SecAzar on our drug pricing blueprint,” Trump tweeted Tuesday night after arriving in Brussels, Belgium, for the NATO summit. “Pfizer is rolling back price hikes, so American patients don’t pay more.”

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Scheussler Stick™ Sales Explode

Tuesday, July 10th, 2018

The Schuessler Stick™, introduced to the market less than one week ago, is surpassing all sales expectations. It’s rumored to be a “must have” for all the attendees of the upcoming SIIA convention in Austin, Texas. Orders are averaging 2,000 per day.

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The 340B Program

Tuesday, July 10th, 2018

For 25 years, the 340B program has provided hospitals with financial help to expand access to life-saving prescription drugs and comprehensive health care services to low-income and uninsured individuals in communities across the country.

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Getting Away With Murder

Tuesday, July 10th, 2018

“Pfizer & others should be ashamed that they have raised drug prices for no reason,” Trump posted on Twitter. “They are merely taking advantage of the poor & others unable to defend themselves, while at the same time giving bargain basement prices to other countries in Europe & elsewhere. We will respond!”

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Detecting Truth, Deception, and Lies

Tuesday, July 10th, 2018

Most people believe they can tell when someone is lying…………….but some can’t. For example, an insurance agent representing a BUCA tells their client they receive no other compensation other than the disclosed PEPM fee. How can one tell if this is a lie………………?

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Let’s Face It – Scott Sterling Never Gives Up

Monday, July 9th, 2018

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David Belk Reports On His RX Findings

Monday, July 9th, 2018

David Belk, M.D.

Hello again everyone, I hope you all had a great 4th of July!

I’m writing you all today to give you two updates about prescription medication costs. The first update has to do with the cost of generic prescription drugs: Their prices went down last year! That’s right, down, by an average of about 12%!!

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The Path To Fixing Health Care Starts With Employers

Sunday, July 8th, 2018

“You don’t need an act of Congress to make a difference when it comes to employer health” – Dave Chase

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The Schuessler Stick™

Saturday, July 7th, 2018

“I always say I have to carry metal rod with the mirror at the bottom of it to run under my car before crank it up”Carl Schuessler

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Benefits Consultants Group

Saturday, July 7th, 2018

Delivering comprehensive resources to the advisor community…………………….

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Is Anything But Status Quo Better?

Tuesday, July 3rd, 2018

When things are so bad that anything different than the status quo is considered a good idea…that’s when we find out just how bad it really can get.

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Who Starts Tyrone’s Car In The Morning?

Tuesday, July 3rd, 2018

How many businesses do you know want to cut their revenues in half? That’s why traditional pharmacy benefit managers don’t offer a fiduciary standard and instead opt for hidden cash flow opportunities such as rebate masking. Want to learn more? – Tyrone Squires

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Managing Risk VS Servicing Risk

Tuesday, July 3rd, 2018

Brokers who survive in the long run will adopt both strategies by aggregating best in class services on a private label basis as a single source comprehensive branded model……………………..This will enable independent brokers to effectively compete with the big boys…………………….

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Nurse Hotline Causes Sharp Increase in ER Visits

Monday, July 2nd, 2018
One time some years ago I implemented a 24 x 7 nurse hotline for a two hundred thousand life group……..

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PillPack Founders, 32 & 35 To Receive $200 Million From Sale

Sunday, July 1st, 2018

The two co-founders of PillPack are set to get about $100 million each in the startup pharmacy’s sale to Amazon.com.

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Amazon + PillPack = Major Market Disruption

Sunday, July 1st, 2018

PillPack is an online pharmacy that packages, organizes and delivers presorted doses of medications.

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Healthcare Price Transparency Ballot Initiative

Sunday, July 1st, 2018

“We launched our advocacy program in Colorado in 2017, and drafted powerful legislation, which will serve as a prototype for our efforts in other states.” – David Silverstein

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Cost Plus Rx Reimbursement Model

Sunday, July 1st, 2018

A cost plus Rx (NADAC + dispensing fee) reimbursement model makes sense…………….

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The Untouchables

Friday, June 29th, 2018

Standard HR demands include:

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Medical Trend For 2019

Friday, June 29th, 2018

Medical cost trend – Behind the numbers 2019

Employer medical cost trend has plateaued. PwC’s Health Research Institute projects employer medical cost trend will be 6 percent for 2019, the same as 2018. Cost reduction efforts will shift to prices.

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David Belk

Friday, June 29th, 2018

Hello Everyone!

I know it’s been a while since I’ve sent out an update, but I’m still busy writing my book (which is taking a lot of my time). I’m nearly done and currently trying to find a publisher (which is also quite difficult). In the meantime, I have updated one of the pages in my website, so I thought I’d share my recent findings with all of you since I think most people will be surprised with what I’ve found.

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Transparency In Retirement Plans – Why Not Health Insurance Plans?

Thursday, June 28th, 2018

Employer thought they were paying their broker $126,000 per year. They were actually paying more than that………………………

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Status Quo Under Attack

Thursday, June 28th, 2018

Traditional health insurers, hospitals and independent physicians who refuse to change will become obsolete…………………………….

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Spreadsheet Fiasco Leads To Firing

Wednesday, June 27th, 2018

AUSTIN — The state has canceled five new managed-care contracts for low-income youngsters enrolled in the Children’s Health Insurance Program after finding errors in a spreadsheet used to evaluate bids.

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Texas County Believes in Magic

Wednesday, June 27th, 2018

A Texas county believes in magic. Facing ever increasing health care costs the county resorts to status quo strategies to temper increases – it’s called cost shifting……………………Meanwhile back at the ranch some Texas political subdivisions are improving benefits and lowering costs at the same time…………………………Health Care Strategies for Political Subdivisions

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Oklahoma Welcomes Medica

Wednesday, June 27th, 2018

Major Health Insurer Medica Brings New Competition to Individual and Family Health Insurance Market in Oklahoma…………………….

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Insurance Giant Acquires Wortham

Tuesday, June 26th, 2018

Wortham Insurance has agreed to a buyout by Marsh, a wholly owned subsidiary of New York-based Marsh & McLennan Companies Inc., combining two well-known names……………..

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Health Insurers Love The “Affordable Care Act”

Tuesday, June 26th, 2018

Health insurers are finding success in ObamaCare this year and are planning to expand their offerings in many states……………………..

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Is It Legal?

Monday, June 25th, 2018

Does anyone know for sure if the Texas Department of Insurance has any jurisdiction over Reference Based Pricing vendors who for a fee indemnify plan members against the risk of lawsuits and balance billing? Is the act of indemnification for a fee through transfer of risk the business of insurance?

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What Causes Hyperinflation in Medical Costs? It’s Health Insurance Stupid!

Monday, June 25th, 2018

Medical insurance directly causes price hyperinflation, because it insulates the patient from the financial impact of their medical care decisions…………………

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The Latest In Texas v. United States

Monday, June 25th, 2018

 

Following the Trump administration’s surprise move not to defend major components of the Affordable Care Act (ACA), much more attention is being paid to litigation over the individual mandate known as Texas v. United States.

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Amazon, Berkshire Hathaway, JP Morgan Target Point of Service Claim Adjudication

Monday, June 25th, 2018

POSCA is coming and it’s gonna be really cool……………………….

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Why Work For A Living When Stealing Is Easier?

Monday, June 25th, 2018

The city of Miami, Miami-Dade County public schools and several companies lost millions of dollars in health insurance payments as a result of being scammed by crooked clinics that submitted bogus claims for pain injections, according to newly filed indictments……………….

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The Impact of Catastrophic Claims  (Plan on Continuing Rate Increases)

Friday, June 22nd, 2018

 The Affordable Care Act did anything but make health care and health insurance more affordable.  The law that was supposed to drive costs down actually did the exact opposite……………………….

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BREAKING: Xerox Can’t Blame Doctors In $1B Texas Medicaid Fraud Row

Friday, June 22nd, 2018

Texas filed suit in May 2014 alleging the Xerox unit then known as ACS State Healthcare LLC, which administered claims for Texas from 2004 until 2012, signed off on $1.1 billion in claims for orthodontic services, a “substantial percentage” of which were allegedly paid in violation of Medicaid policies….…………….

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Government-Enabled Kickbacks Escalate Medical Prices

Friday, June 22nd, 2018

 

“Since the federal healthcare Anti-Kickback Statute GPO exception was created 30 years ago, the landscape has changed. The current GPO funding structure’s incentive is to ‘negotiate’ higher prices for its customers. The vendors with the most money can afford to pay the high fees and buy themselves into the game. The term ‘payola’—pay to play—comes to mind. The situation is exacerbated because insurers absorb the higher prices and thus hospitals may have less incentive to monitor pricing.”

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Must Reference Based Pricing Vendors Be Licensed?

Thursday, June 21st, 2018

Hospitals and their attorneys are getting creative. One issue of particular interest outlined in the article is apparently a new line of attack……………………..

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We’re not good golfers…………………

Thursday, June 21st, 2018

This is one of the best insurance agency websites I have seen in a long time. They memorialize their philosophy in a compelling manner………………………….

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Embodiment of Corruption: Your Health Insurance Network

Thursday, June 21st, 2018

Secret network pricing helps render patients defenseless against price gouging. It’s as absurd as grocers being permitted to keep the price of milk secret……………..

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Government Control of Health Care Loosened in Bold Move

Thursday, June 21st, 2018

Move keeps the government officials from using its power and influence to direct the practice of medicine……………………….

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Why Do Prescription Prices Vary By Up to 1,300%

Thursday, June 21st, 2018

Learn how a recent study found that prices for 5 commonly prescribed prescription drugs varied but up to 1,300% based on where the drugs were purchased.

Montana Experiences “Holy Cow” Moment

Thursday, June 21st, 2018

Montana’s high-stakes game of chicken designed to change how the state did business with its 60 hospitals, which accounted for 43 percent of employee health care costs, turning the normal purchasing process on its head……………………..

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Sana

Thursday, June 21st, 2018

Are you looking for new commission and bonus opportunities: Join us for a catered lunch at one of our local Texas events to learn how Sana is changing health insurance. Plus meet the founders.

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Reference-Based Pricing Litigation: Brick By Brick

Thursday, June 21st, 2018

By Scott Bennett – www.linkedin.com/in/scott-bennett-72014594/

Whether you believe modern Reference-Based Pricing models are presently being built, remodeled, or dismantled “brick by brick” truly depends on your perspective. Either way, this is an interesting time to review the recent challenges, results, and future risk created by this important approach to health care reimbursement, which has saved employers millions of dollars and sparked fierce conversations about reasonable value across the nation.

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Renting Medicare’s Provider Network

Wednesday, June 20th, 2018

 democratrepublican

An idea with bi-partisan support?

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Association Health Plans Go Into Effect

Wednesday, June 20th, 2018

This expansion of health care choices returns certain risk manager tools stolen by the government with the passage of the Affordable Care Act (ACA):

☐ Allows plans to exclude coverage for maternity care, prescription drugs, mental-health services and other ‘essential health benefits’ the ACA requires of coverage

☐ Plans will have more freedom to charge different prices depending on customers’ ages, genders and locations — something ACA coverage cannot do.

☐ The regulations erase a requirement that any association must already have existed for a purpose unrelated to health insurance.

☐ These plans will also be able to reduce administrative costs and strengthen negotiating power with providers from larger risk pools and greater economies of scale….

☐ Moves health-insurance regulation from the state level to the federal level.

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Peeling Back The Health Care Onion

Tuesday, June 19th, 2018

“Colorado hospitals statewide are paid an average of 290% of Medicare for inpatient services and 520% of Medicare for outpatient services…………………”

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Unwieldy Health Costs Often Stand Between Teachers And Fatter Paychecks

Tuesday, June 19th, 2018

In an era of $100,000-a-year drugs and government budget cuts, school districts are struggling to find the money to keep up their end of the bargain (providing benefits), forced to take away from classroom funding and even modest, cost-of-living raises. Many cash-strapped school boards, cities and legislatures view health care benefits as an unpredictable budget-buster.

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Don’t Hire An Actuary Because You May Get Really Bad News

Tuesday, June 19th, 2018

As a benefits consultant, if you not employing a licensed actuary providing these services your competition will……………………………..

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McAllen Independent School District Seeks Reference Based Pricing Vendor

Monday, June 18th, 2018
The McAllen Independent School District in deep South Texas is seeking competitive proposals for Reference Based Pricing plan administrator. Sources say the district is facing increasing health care costs and seeks to adopt a Reference Based Pricing plan option to offer in addition to their current PPO plan.

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Why You Will Never Win

Monday, June 18th, 2018

This was sent to several of us this afternoon from the one and only, Carl Schuessler, health care disruptor extraordinaire.

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Introductions Are Worth Big Bucks In The Insurance Industry

Thursday, June 14th, 2018

Earning commissions forever by simply making an introduction beats working for a living………….

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Owe Medical Bills? Don’t Pay Promptly, Pay Late & Join The 50% Club

Wednesday, June 13th, 2018

Members of the 50% Club subscribe to the Upside Down Economics of Health Care. They understand those who pay on time are screwing themselves and those that don’t are rewarded…………….

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Everyone Is Paying For Mary’s Deductible Because Mary Isn’t

Tuesday, June 12th, 2018

Lucky Mary is even more lucky now that her employer decided enough was enough…………………….

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Saving Rural Hospitals By Gaming The System?

Monday, June 11th, 2018

GAMING THE SYSTEM: Remote billing by rural hospitals is becoming a strategy to remain solvent? Medicare and commercial insurers tend to pay more for tests to sustain endangered rural hospitals compared with urban hospitals and especially outpatient labs………………………………

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Medicare For All & Reference Based Pricing

Monday, June 11th, 2018

Since Medicare For All is only a few elections away some employers are asking “Why wait? Let’s do it!

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Schools Buying Insurance Against Mass Shootings On The Rise

Sunday, June 10th, 2018

McGowan Cos., the largest underwriter of “active shooter” coverage, said they’re having a tough time keeping up with hundreds of inquiries from schools and other customers……………….

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PUNISHMENT LETTER 226-J

Saturday, June 9th, 2018

The government of the United States has sent out 30,000 punishment letters to employers who have failed to comply with the ever so popular AFFORDABLE HEALTH CARE ACT…………………………..

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Justice Dept. Says Crucial Provisions of Obamacare Are Unconstitutional

Friday, June 8th, 2018

Is it a tax if it raises no revenue………………………………….?

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Single Payer System Is One Election Away

Friday, June 8th, 2018

The Elephant In The Room is stirring, anxiously awaiting the fall mating season……………………….

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