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1. CONFIDENTIALITY NOTICE: This letter is intended only
for the use of the individual or entity to which it
2. is addressed and may contain information that is
privileged, confidential and exempt from disclosure
3. under applicable law. If you have received this letter
in error, please do not distribute. Please notify the
4. sender by e-mail at firstname.lastname@example.org. Thank you for
5. DUE DILIGENCE: Gloria Stezzi calls to the attention of
Kenneth Fody, Esquire, Keystone Legal
6. Department manager, Independence Blue Cross,
the fact that the documents contained in this
7. presentation provide evidence of negligence and
wrongdoing by the University of Pennsylvania Medical
8. Center and its Penn Health system, which includes its
in-house Department of Orthopaedic Surgery,
9. which must be prosecuted.
Otherwise, Keystone would be guilty of
10. Gloria Stezzi
12. Philadelphia, PA 19148
13. September 3, 2002
14. Keystone Health Plan East
15. Patient Care Management Department
16. Post Office Box 7890
17. Philadelphia, PA
18. Attention: Internal First Level Grievance
19. SUBJECT: Patient, Gloria Stezzi, grieves the Keystone
Health Plan East's Explanation of Benefits' denial
20. of payment to Dr.Salvo of Philadelphia Orthopedic
21. RE: Explanation of Benefits
23. Claim Number
24. Patient Name
Stezzi, Gloria, J.
25. Provider Name
Philadelphia Orthopedic Associates
26. Member ID Number XXXXXXXXXX
27. Group Number 600180
28. NOTE: All documents referenced are attached.
29. Dear Keystone Health Plan East:
30. Gloria Stezzi, under the direction of Rocco Stezzi,
submits the following grievance necessitated by the
31. receipt of the above referenced Explanation of
Benefits statement metered on July 8, 2002 in Harrisburg.
32. GLORIA STEZZI contests the Keystone Health Plan East
denial of payment for services by
33. Philadelphia Orthopedic Associates, hereinafter
referred to as DR.SALVO, with the Reason Code
34. A003 "SERVICE NOT AUTHORIZED BY PCP: MEMBER NOT
35. DR.SALVO is entitled to payment for services.
36. Both GLORIA STEZZI and DR.SALVO on 5 December
2001diligently requested a written referral from
37. GLORIA STEZZI's Primary Care Physician, Dr. Mignott,
hereinafter referred to as PCP, of the Penn
38. Health system, after the in-house Department of
Orthopaedic Surgery, of the same Penn Health system,
39. unilaterally terminated the treatment of GLORIA
STEZZI on 4 December 2001.
40. The Penn Health Care system PCP on 5 December 2001,
after the in-house Department of Orthopaedic
41. Surgery of the same Penn Health system unilaterally
terminated the treatment of GLORIA STEZZI on 4
42. December 2001, refused requests from both GLORIA
STEZZI and DR.SALVO to write a referral until
43. after the Nationwide medical benefits were exhausted.
44. At the time Keystone Health Plan East, hereinafter
referred to as Keystone, was not the primary insurer.
45. GLORIA STEZZI under the Pennsylvania Auto Insurance
Law, Act 6 had to use Nationwide Mutual
46. Insurance Company as the primary insurer not Keystone
up to the medical liability limit of the policy.
47. The Penn Health system PCP on 5 December 2001
attempted to evade the referral rules of Keystone
48. Health Plan East with a sham promise to write a
referral when Keystone became the primary insurer.
49. GLORIA STEZZI and DR.SALVO had no way of knowing when
that time had arrived. Keystone's
50. processing department rules apparently required the
PCP to write a referral dated 4 December 2001, the
51. time that the in-house Department of Orthopaedic
Surgery of the same Penn Health Care system
52. unilaterally terminated the treatment of GLORIA
53. But when GLORIA STEZZI started treatment with
DR.SALVO Keystone under Pennsylvania law was not
54. the primary insurer.
55. The Penn Health system, which includes the University
of Pennsylvania Medical Center's in-house
56. Department of Orthopaedic Surgery, scammed both
GLORIA STEZZI and DR.SALVO.
57. It deliberately created an impossible "catch
22" situation for both GLORIA STEZZI and DR.SALVO.
58. The PCP on 5 December 2001 refused to issue a
referral because Keystone was not the primary insurer,
59. Keystone requires a referral from the PCP written on
4 December 2001 when Keystone was not the
60. primary insurer.
61. Furthermore, the University of Pennsylvania Medical
Center's in-house Department of Orthopaedic
62. Surgery unilaterally terminated the treatment of
GLORIA STEZZI on 4 December 2001with written
63. notification that GLORIA STEZZI was to seek treatment
64. Gloria Stezzi will prove with well-documented facts
that the PCP, under instruction from Penn Health
65. system in-house Department of Orthopaedic Surgery, on
5 December 2001, refused to write a referral to
66. evade accountability for the Department of
Orthopaedic Surgery's missed diagnosis and inappropriate
67. treatment and for the Department of Orthopaedic
and unlawful conduct.
68. Thus the Department of Orthopaedic Surgery on 4
December 2001 avoided a certain complaint to
69. Keystone from GLORIA STEZZI.
70. Nationwide Mutual Insurance Company, of course, can
only pay the valid bills submitted up to the
71. medical liability limit of the policy. There is no
provision for reporting bad medical service.
72. WHEREFORE, GLORIA STEZZI requests that DR.SALVO be
paid for services grieved.
73. DISCUSSION OF THE CASE
74. The Auto Accident and Insurance
75. GLORIA STEZZI suffered injuries to the right foot and
ankle on 24 October 2001 when struck by a motor
76. vehicle insured by Nationwide Mutual Insurance
77. At the time GLORIA STEZZI
was employed by Mellon Bank, but its retail banking business
78. sold to Citizens Bank.
GLORIA STEZZI was covered by Keystone Health Plan East group
79. insurance through December 31st 2001.
GLORIA STEZZI had been scheduled to be covered by
80. Highmark group medical health insurance from the new
employer Citizens Bank on 1 January 2002.
81. Keystone Health Plan East is an HMO which uses a
primary care physician referral system. Highmark is
82. not an HMO and does not use a primary care physician
83. As a result of the accident GLORIA STEZZI immediately
went on short-term disability. The
84. Auto Insurance Law, Act 6 dictates that the auto
accident medical bills of GLORIA STEZZI first be paid by
85. the auto insurance company until the limits of the
medical liability coverage is reached.
When the auto
86. accident medical liability coverage is exhausted,
under the law, GLORIA STEZZI's health care insurer,
87. Keystone must then take over payment of the medical
88. DETAILED SUMMARY OF MEDICAL EVENTS THROUGH 9 NOVEMBER
89. Gloria Stezzi was struck on the left side, turned
around, and landed on her back in the street crosswalk.
90. Her right lower leg was struck. Her foot was hyper-extended and crushed as the pickup truck
91. over it. Within the hour she received an emergency
diagnosis and stablization of the injury at Methodist
92. Hospital on 24 October 2001.
93. The treatment consisted of an uncertified x-ray, a
posterior splint, crutches for non-weight bearing and
94. instructions to consult with an orthopedic surgeon.
95. There was no licensed radiologist available to read
96. The cost-cutting hospital policy was not to have an
orthopedic surgeon involved unless the injury was life
98. On 25 October 2001 at the University of Pennsylvania
School of Medicine, Hospital of the University of
99. Pennsylvania, Department of Orthopedic Surgery Ernest
J. Gentchos, MD prescribed a cast. No x-rays
100. were taken that day. Dr. Gentchos used only the
crude Methodist Hospital x-ray.
101. On the follow-up visit on 1 November 2001 Dr.
Gentchos ignored the foot pain complaints of Gloria Stezzi
102. and did nothing with the cast.
103. On Friday, 9 November 2001 Gloria Stezzi scheduled
an emergency visit with Dr. Gentchos to investigate
104. the pains that she was experiencing in the now very
105. An x-ray was taken through the original fiberglass
cast on the foot. Nothing else was done.
106. Gloria Stezzi called Rocco Stezzi from the telephone
in the lobby of the Hospital of the University of
107. Pennsylvania at 12:30p.m.
Gloria told Rocco over the telephone that Dr. Gentchos had
given her a letter
108. for her employer dated 25 October 2001 that gave a
diagnosis of displaced fracture of the distal right fifth
109. metatarsal. Rocco immediately called Dr. Gentchos
and left a message for him. At
exactly 5:12 p.m. on 9
110. November 2001, Dr. Gentchos returned Rocco's call.
The telephone number 215 349 8683 was recorded
111. on the caller ID.
Dr. Gentchos set up an informal meeting with Rocco at 1:00 p.m.
on 12 November 2001
112. to explain the x-rays and diagnosis. Dr. Gentchos
also said that he was scheduled at that time to be at
113. the Penn Towers student clinic.
114. Rocco and Dr. Gentchos did meet at 1:00 p.m. on 12
November 2001 but Dr. Gentchos chose not to
115. explain the x-rays and diagnosis.
116. At that point, given the seriousness of the
previously undisclosed diagnosis sent to her employer and the
117. refusal of Dr. Gentchos to discuss the matter, Rocco
and Gloria requested X-Ray proof of the
118. unsubstantiated diagnosis. What occurred next were
blatant and outrageous violations of Keystone's
119. Contractually guaranteed Member's rights of Gloria
Stezzi and the Pennsylvania Patient Bill of Rights
120. posted in every Hospital for at least the last five
121. The following are key quotes and basic analysis of
the documents generated through November 9th by
122. the University of Pennsylvania School of Medicine,
Hospital of the University of Pennsylvania,
123. Department of Orthopedic Surgery, Penn Health
124. Medical Report Documentation
125. Report Submitted To Employer For Disability
126. The letter dated 25 October 2001, with the signature
of Ernest J. Gentchos, M.D., is needed by the
127. employer of Gloria in order for her to receive
1. "there is swelling at the dorsal aspect of her
right distal foot as well as ecchymosis on the dorsal
128. lateral aspect of her foot as well as her fifth toe
and somewhat on the fourth toe as well."
2. -"The x-ray examination demonstrates a displaced
fracture of the distal right fifth metatarsal."
3. -"The patient was casted in a short-leg walking
fiberglass cast and she will partially bear weight with
4. -"Six weeks immobilization is planned."
130. One Week Re-Evaluation
131. The 11/01/01 medical notes, with the signature of
Ernest J. Gentchos, M.D., contain a correction. The
132. word "interspace"
was crossed out and corrected with the word
"avulsion" over the top of it. There were
133. no initials and no signature. -"The patient
comes in for follow-up evaluation with regard to avulsion
134. fracture of the fifth metatarsal for her right
5. -"She will return in six weeks for cast removal
and follow-up x-ray."
135. Emergency Appointment For Pain Investigation
136. The 11/09/01 medical notes, with the signature of
Ernest J. Gentchos, M.D. were written after an x-ray
137. was performed through a cast. -"Ms. Stezzi
comes in because she has some pain over the fracture site."
6. -"The patient has a fracture of the fifth
metatarsal distal third.
7. -"A follow-up x-ray was performed and the
fracture remains well aligned."
138. X-Ray Report On 11/09/01
139. The 9 November 2001 "film" report,
apparently read by Ernest J. Gentchos, M.D. and then approved by J
140. Bruce Kneeland, MD was without signatures.
-"The study is performed through a cast which obscures fine
141. osseous and soft tissue detail."
10. -"There is a poorly visualized, nondisplaced
traverse fracture through the distal fifth metatarsal shaft."
11. -"I [J. Bruce Kneeland, MD] certify that I have
personally reviewed this examination, and agree with
142. this report."
143. Comment On Medical Notes Of The Three
144. From an orthopedic surgeon's perspective the medical
notes on each of the three days describe three
145. distinctly different injuries.
146. On October 25th the diagnosis of a displaced
fracture of the distal right fifth metatarsal is made.
147. On November 1st an avulsion fracture of the fifth
metatarsal for her right foot is diagnosed.
148. On November 9th a nondisplaced traverse fracture
through the distal fifth metatarsal shaft is diagnosed.
149. The physiology of the fifth metatarsal is such that
a simple fracture at its base heals faster than at its
150. neck. The
blood supply to the neck is poor when compared to the blood supply at
the base of the fifth
151. metatarsal in a healthy foot.
152. Normal foot injuries are the result of applying too
much stress to the foot. The bone breaks and heals.
153. In the instant case the foot was crushed under the
wheel of a pickup truck. The foot had bone fracture
154. injuries and extensive soft tissue damage.
155. Even a person with no knowledge of medicine knows
that a displaced fracture is the opposite of a
156. nondisplaced fracture.
The displaced fracture usually requires an operation.
Further, the avulsion
157. fracture occurs at the proximal fifth metatarsal and
not the distal fifth metatarsal.
The distal portion of the
158. metatarsal includes the head, neck, and connecting
shaft. The proximal
portion of the metatarsal, which
159. may be four to five inches away from the head of the
metatarsal, includes the base and two incredibly
160. strong tendons.
161. In certain types of injuries the tendons can
actually pull the bone at the base of the metatarsal apart
162. causing a "tuberosity 'avulsion'
163. When the x-rays were taken on 9 November 2001 the
cast effectively filtered out all the detailed
164. information about the injury except gross alignment
of dense bone structure. The
detailed information on
165. the actual fracture and the extent of the healing
progress could not be determined from the x-rays taken
166. through a cast.
In the "clean up state" of the normal bone fracture
healing the ends of the injured bone
167. are removed by the body and new bone will grow to
bridge the gaps. An x-ray taken at the termination of
168. the cleanup stage will capture the full extent of
the fracture. The analogy
to a picture of railroad tracks
169. after the damaged section is removed is applicable.
The doctor only wanted to show that the railroad
170. track bed had not shifted any more. The doctor did
not want to document how many miles of rails were
171. missing and had to be rebuilt.
172. The patient is not shown the X-ray. The X-ray of
Gloria Stezzi at six weeks taken by Dr. Salvo when he
173. removed the cast showed a big empty space where the
body had removed all the crushed bone
175. A Cultural of Corruption: The Penn Health System
176. A simple internet search of recent newspaper
articles reporting on Penn Health Systems turned up many
177. cases of civil and criminal prosecution. These
included the Department of Orthopedic Surgery and its
178. administration where surgeons bill for operations
they did not perform and managers steal money. In
179. 1995 the figure was a $30 million dollar fine for
false billing. In 2000 it
was $12 million. In 2001 it was
180. $1.89 million. The Penn Health Systems lost $198
million dollars in 1999 and $168 million in 2000. In
181. 2001, when Gloria Stezzi was treated, after severe
cost cutting, it turned a small profit.
182. The documents generated after 9 November 2001 expose
a systemic pattern of corruption at Penn
183. Health system. The writers of the letters
deliberately do not conduct due diligence in the accuracy of the
184. statements contained in the letters.
The writers of the letters have no first-hand information of
185. contained in a letter. Authentication of the facts
186. The writers were chosen for their apparent lack of
knowledge. This minimizes
the legal liability. The
187. purpose of the letters seems to document
unsubstantiated hearsay. This
action is the tactic of an
188. unethical lawyer.
In court the letter writer usually claims that he was
misinformed or misunderstood or
189. misled. The letter writer will swear that to the
best of his knowledge no report contained a material untrue
190. statement or omitted a material fact necessary to
make the report not misleading.
191. A material fact is generally viewed as one that a
reasonable juror would want to know.
192. In fact the authors of the letters, notes, and
reports not only wrote numerous untrue statements of
193. material fact but also omitted to state the material
facts necessary to make the statements in the covered
194. documents, in light of the circumstances under which
they were made, not misleading.
195. A distinction is made between author and writer.
The writer is the person who signs his name.
196. author is invariably a lawyer from the legal
department. The writer is
little more than a legal department
198. The Penn Health system employs a literal army of
security guards for the buildings and a university police
199. force for the grounds. The university police
misrepresent themselves as Philadelphia City police officers.
200. There is also a special unit of little more than
common thugs used to assault and verbally abuse patients
201. who dare to assert their Keystone Member Rights or
Patient Rights under Pennsylvania law.
202. When you are dealing with unscrupulous people who
manipulate everything to get there own way nothing
203. you say or do will enable you to receive fully that
to which you are entitled. You
cannot deal with a
204. person lacking in honesty and integrity.
Such a person cannot be trusted.
Your rights and your personal
205. dignity should be respected but instead you are
subjected to public humiliation.
206. Undiagnosed Injury
207. Gloria Stezzi documents for the record that ten
months after she was treated at Penn Health system she
208. is attempting to avoid surgery by wearing a
"premium Walker" shoe boot to hopefully coax the
209. undiagnosed automobile accident injury to heal on
210. The Penn Health System Cover-up from 12 November
2001 to 5 December 2001
211. What you are about to ingest is only a taste of the
Penn Health system cover-up sufficient to prove the
212. willful denial of a referral for this grievance.
The main dish is in the oven.
213. Legal or the lawyers of the Penn Health system risk
management department digesting the above
214. medical records surely experienced an acute
heartburn attack.The in-house Department of Orthopedic
215. Surgery has failed to make even a definite diagnosis
of the injury to Gloria Stezzi from the automobile
216. accident. In
fact, Dr. Gentchos has done nothing but take the obviously limited
diagnosis of an
217. emergency room resident doctor based on a crude
x-ray and slapped a full lower leg cast on the injury.
218. The patient, Gloria Stezzi, experiencing intolerable
pain, had to make an emergency visit to Dr. Gentchos
219. on 9 November 2001.
220. Instead of removing the sixteen day old cast to
properly observe and diagnose the source of pain, Dr.
221. Gentchos orders another crude x-ray done with the
aggravating cast still on. Dr.
Gentchos just tells
222. Gloria Stezzi to go home.
Gloria calls Rocco, her husband, and complains that the doctor
is ignoring her
224. Rocco, who has taught the design of basic computer
logic circuits, and diagnostic decision logic tables,
225. and troubleshooting, after analyzing the situation,
including Dr. Gentchos' letter to Gloria Stezzi's Penn
226. Health System Primary Care Physician, Dr. Mignott,
determined that Dr. Gentchos has been negligent.
227. Dr. Gentchos has not gathered sufficient data either
through physical observation or instrument testing to
228. make a valid comprehensive diagnosis of all the
injuries sustained in the accident.
Gloria Stezzi had her
229. lower leg, ankle, and foot smashed, crushed and
stretched but no attempt was made to diagnose the
230. injuries to the soft tissues such as the tendons,
ligaments, muscles, nerves, blood vessels etc. You must
231. identify or define the problem before treatment or a
solution is possible.
232. The primary purpose of this grievance is to supply
evidence to justify the payment of benefits by Keystone
233. to Dr. Salvo who was refused a referral from the
Penn Health system PCP. It
is sufficient to show that the
234. writing of a referral was denied by the legal
department or risk management of the Penn health systems
235. as a desperate attempt to evade accountability to
Keystone for violating the contractual Members Rights
236. and to cover-up its misconduct and negligence.
237. Therefore the focus of the analysis of the following
documents is to be the clear evidence of the
238. unprofessional and unlawful conduct to evade
accountability and deny Gloria Stezzi and Dr. Salvo a
240. The 12 November 2001 Letter
241. As stated previously, the "purpose of the
letters seems to document unsubstantiated hearsay". The letter
242. violates the rules for medical report writing. A
medical chart or incident report does not include
243. inflammatory words or judgmental statements. What is
"being extremely difficult and rude" or "was rude
244. and very obnoxious" mean? Where is the
statement of facts? Where is the objective description of the
245. subject's actions? Its no wonder the Doctors can not
make a valid diagnosis!
246. The letter states, "The Patient then through
her primary care physician, Dr. Harold Mignott requested a
247. physician here at Penn... ." This of course could be considered the smoking gun and the
proof needed to
248. prove the case. Unfortunately it is hearsay in a
letter that contradicts more than it confirms in the
249. previously discussed documents.
250. For your own amusement try finding how many medical
statements in the 12 November 2001 letter
251. contradict the medical statements in the previous
documents. Remember these are not mere mortal men
252. they are the Professors teaching the new interns and
residents. Heaven help us!
253. (As an aside, Gloria Stezzi sent a certified letter
[not attached] to Garry L. Scheib, Executive Director
254. requesting, "The author must certify that the
following statements contained in the document are true and
255. correct and not intentionally meant to be false and
misleading". He denied the request.)
256. The absolute proof of the lack of veracity of the
statements contained in the document is in the income
257. statement. Dr. Gentchos never submitted a bill and
there is no medical report from him on 12 November
258. 2001 for the evaluation indicated in the letter. It
never occurred! Dr. Okereke also never submitted a bill.
a. The COMMENTS section on page two are in the same
category as Dr. Gentchos' evaluation. But here is
259. a prime example where a report contained a material
untrue statement and omitted a material fact
260. necessary to make the report not misleading.
261. Gloria requested the cast be removed, that x-rays
and an ultrasound be taken, and that she be fitted with
262. a shoe boot. Dr. Okereke refused to take x-rays
under any conditions to document the condition of the
263. injury, but told Gloria that he would remove the
cast and that she could go elsewhere for treatment.
264. That was a very sadistic comment for a Doctor to
265. The letter also contains libelous statements that
can not be addressed at this time.
266. The 4 December 2001 Letter
267. Between 13 November 2001 and 30 November 2001 there
were many phone calls, letters and faxes back
268. forth which add nothing to the referral issue of
269. But on November 30th, 2001 Wanda Seamon, patient
services representative, called Gloria and told her
270. that she had set up an appointment for her at
9:00a.m. on December 4 with Dr. Heppenstall.
271. The resulting 4 December 2001 letter of termination
is the final testimony to the Penn Health system
272. culture of corruption.
273. True to the modus operandi of "Penn Health
'legal'" the letter is written by Rachelle Little who documents
274. hearsay. Neither Gloria nor Rocco have any knowledge
of Rachelle Little. The
relevant statements are
275. flat out lies.
The fabricated first paragraph is as follows:
i. This letter will confirm that you have decided not to
keep your appointment with Dr.
276. Hepenstall scheduled for 9:00 a.m. today.
You have advised that you do not wish to receive
277. further treatment from the orthopaedic surgeons
associated with the Hospital of the University of
278. Pennsylvania and that you intend to seek medical
care from another physician.
279. In fact, Gloria and Rocco arrived at the 2nd floor
sign-in desk at 8:57 a.m. Gloria
printed her name on the
280. chart label because the computer was down.
At 9:03 a.m. two security guards named Jeffrey Harris and
281. Sgt. O'Keefe escorted us down to the lobby.
There we sat until 3:40 p.m. when we were handed the 4
282. December 2001 letter.
283. In the interim, at our request, we were escorted by
the security guards to visit Wanda Seaman at 9:10
284. a.m. whose office is in the corridor leading from
the main lobby. She gave the explanation that "legal"
285. would not permit it.
286. At 11:20 a.m. Eileen Frierson, supervisor of Ms.
Seamon, at our request, spoke with us. We were denied
287. a private meeting room and were forced to talk in
the open public lobby.
288. At 12:22 p.m. A. Glogower, Director of security,
tried to pass himself off as a physician with Ms. Frierson.
289. Rocco requested he produce some identification.
After 5 minutes he produced his business card.
290. At 3:30 p.m. Ms.Frierson came down with old x-ray
and requested a signature. Rocco
advised Gloria not
291. to sign anything because "they cannot be
trusted". Gloria advised Ms. Frierson that she had sat there all
292. day waiting to be seen by a Penn surgeon.
293. Letter of Termination Delivered
294. At 3:40 p.m. someone came down and delivered the 4
December letter and requested that we leave.
295. Office of PCP Refuses Request for Referral
296. The next day, December 5th, after many phone calls
to the PCP office, at 10:04 Linzie the referral person
297. informed us that no referral would be written until
the benefits of the automobile insurance were
299. This is the end of the Penn Health system corruption
saga and of this grievance discussion.
300. Yours truly,
301. Gloria J Stezzi
302. 2442 South Mildred Street
303. Philadelphia, PA 19148-3720
304. Prepared by:
305. Rocco S Stezzi
306. INTERNAL GRIEVANCE KHPE
308. Page 9 of 9
309. Page 9