The Silent PPO Dilemma: California

1
The Silent PPO Dilemma Californias Medical
Providers Harmed by Stealth Contracts
Thursday, May 1, 2008 1100 a.m. Pacific Time By
Reid L. Steinfeld, Esq. David Bryan Leonard,
Esq.
2
Important Terminology

• Preferred Provider Organizations (PPO) give
  discounts for increased patient volume.
• PPO Contract- A contract entered into by the
  provider and a network. The provider receives a
  referral, steerage, and/or preference, in return
  the provider discounts its medical fees.
• Health Care Contract- policies are issued to
  ensure members are identified by membership ID
  cards.

3
Important Terminology Continued

• Silent PPO- A Silent PPO is created when the
  PPO gains additional revenue by selling its
  reduced provider rates to payors (i.e. Work Comp
  Insurers) who are not a part to the preferred
  rate agreement with provider panels and who do
  not provide incentives for their beneficiaries to
  see these providers.

4
TWO TYPES OF PPO CONTRACTS

• A contract in which the network contracts with
  the provider, for the network to sell its health
  care services at the contract rates agreed upon
  in turn for additional patients.
• A Health Care Insurance Company that enters into
  contract with provider to treat their members of
  the insurance company issuing policy to its
  members at the discounted contract rates.

5
THE PROBLEM

• A billion dollar industry has been created by
  selling the contract discounts of PPOs, for
  patients that are not members of the network for
  a fee.

6
HOW IT WORKS

INSURANCE COMPANIES
HOSPITAL/PROVIDER
Patient with workers compensation insurance
seeks treatment at hospital/provider. Insurance
is verified.
Hospital bills insurer fee schedule or usual and
customary charges services.
1
Hospital/Provider generally too busy to cross
check to see if discount valid.
Hospital gets a reduced payment from insurer
along with EOB that says patient was entitled to
the discount through silent PPO.
6
Insurance Company
5
BILL REVIEW CO/ BROKER (SILENT PPO)
PPO
2
Review Co/Broker identifies PPO that has an
agreement with hospital and obtains discounted
fee Information from the PPO.
Review Co./Broker sells that information to
insurer
4
Insurer contact broker of PPO discounts.
Referred to as non-directed or silent PPO.
3
7
First Case to Give the Board Jurisdiction

• Nico Zuniga, Applicant v. Herb Steward, State
  Compensation Insurance Fund, Defendants,
• 2002 Cal. Wrk. Comp. P.D. LEXIS 104, Opinion
  Filed June 13, 2002
• While SCIF may have been a third-party
  beneficiary to the Blue Cross/Cedars-Sinai
  agreement in a Civil Code or Commercial Code
  setting, they may not assert such a right in a
  Workers Compensation case where Labor Code
• section 5304 applies. This Labor Code section
  requires an express agreement, whether oral or
  written, between the provider and the employer or
  carrier. This provides a higher standard than
  civil or commercial contract law.
• The case also held that State Compensation
  Insurance Fund was entitled to the PPO discount
  of the Blue Cross contract.
• When the case came out providers ready and
  willing to litigate based on the above case were
  dissuaded by direct asserts by Blue Cross that
  they considered such litigation a breach of their
  Blue Cross contract. Therefore, a mass
  litigation did not appear only a few providers
  continue to fight the Silent PPO issues.

8
OTHER CASES THAT ADDRESS LABOR CODE 5304
(JURISDICTION)

• Maria Molina, Applicant v. Best Western Park
  Place Inn, State Compensation Insurance Fund,
  Defendants, 2005 Cal. Wrk. Comp. P.D. LEXIS 19,
  Opinion Filed February 7, 2005.
• Labor Code Section 5304 states
• The appeals board has jurisdiction over any
  controversy relating to or arising out of
  Sections 4600 to 4605 inclusive, unless an
  express agreement fixing the amounts to be paid
  for medical, surgical or hospital treatment as
  such treatment is described in those sections has
  been made between the persons or institutions
  rendering such treatment and the employer.
• There is no contention by SCIF that an agreement
  fixing fees exists between SCIF and
  BMC(Bellflower Medical Center). Thus, this Court
  finds that jurisdiction exists to resolve this
  fee dispute between SCIF and BMC.

9
OTHER CASES THAT ADDRESS LABOR CODE 5304
(JURISDICTION)

• Virginia Woodruff, Applicant v. Greenfield
  Trucking, State Compensation Insurance Fund,
  Defendants, 2007 Cal. Wrk. Comp. P.D. LEXIS 93,
  Opinion Filed September 4, 2007
• Labor Code Section 5304 provides
• The appeals board has jurisdiction over any
  controversy relating to or arising out of
  Sections 4600 to 4605 inclusive, unless an
  express agreement fixing the amounts to be paid
  for medical, surgical, or hospital treatment as
  such treatment is described in those sections has
  been made between the persons or institutions
  rendering such treatment and the employer or
  insurer.
• In this case, there is no evidence of an
  express agreement between the rendering
  institution, Good Samaritan Hospital and the
  insurer State Compensation Insurance Fund (SCIF).
  The only express agreements in evidence are
  between Good Samaritan Hospital and Blue Cross,
  and a separate agreement between Blue Cross and
  SCIF Two years separates the two agreements. At
  best, SCIF is a third party beneficiary, in a
  contractual sense, to the Good Samaritan/Blue
  Cross agreement. Since there is no express
  agreement between the institution rendering
  treatment (Good Samaritan Hospital) and the
  insurer(SCIF), the appeals board has proper
  jurisdiction over the matter under Labor Code
  section 5304.

10
JURISDICTION UNDER LABOR CODE 5304

• This case differs from the previous in that it
  was a brokerage contract. The case stated that
  since there were three contracts that was
  sufficient to deny the WCAB of Jurisdiction.
• Sarah Waters, Applicant v. Los Angeles Clippers
  Basketball Club, Inc. TIG Specialty
• Insurance Solutions c/o Cambridge Integrated
  Services Group, Inc., Defendants,
• 2005 Cal. Wrk. Comp. P.D. LEXIS 15, Opinions
  Filed February 7, 2005 and April 26,
• 2005
• The background to this issue is that CCN is in
  the business of preparing contracts and referring
  patients to doctors or hospitals, and there are
  other various aspects of its business as well,
  and CCN entered into a contract with Good
  Samaritan Hospital, under the terms of which Good
  Samaritan Hospital would accept for payment of
  medical treatment according to a scheduled fee.
  Later on, CCN entered into a separate contract
  with TIG.

11
REVIEW COMPANY CUTS OFF BROKERAGE CONTRACT

• Richard Balzano, Applicant v. City of Los
  Angeles, PSI, Defendant, 2005
• Cal. Wrk. Comp. P.D. LEXIS 16, Opinion Filed
  April 13, 2005
• The parties stipulated at trial that
  Diversified is listed as a payor on CCNs payor
  list. According sic the definition of payor
  (supra), Diversified can only be classified as
  such in the capacity of an employer. They are
  not an insurance carrier, health care service
  plan, non profit hospital service plan, nor a
  governmental unit or any other entity which has
  an obligation to provide medical benefits to a
  beneficiary. Diversified can be a payor only
  in so far as their own employees (i.e.
  beneficiaries) are concerned. Testimony at trial
  was that Diversified did not pay any of the City
  of Los Angeles bills. They merely provided bill
  review and discounts and told the City of Los
  Angeles what they recommended the City pay. The
  City of Los Angeles actually paid the bills for
  medical treatment in this case.

12
MORE ON REVIEW COMPANIES

• Susan Olsukka v. City of Sacramento 2005 cql.
• Wrk Comp. P.D. LEXIS 27 Filed August 11, 2005
• It must be kept in mind that it was defendant,
  not Cambridge, that retained or authorized the
  services of lien claimant in this case. The
  evidence indicates an after-the-fact reduction by
  Cambridge based on a contract, that was never
  offered into evidence. Without this contract, the
  WCJ was, and remains, unable to determine if lien
  claimant agreed to be bound by the PPO price any
  time an employer or carrier retained Cambridge to
  review a bill.

13
NO PRIVITY NO CONTRACT

• John Miranda, Jr., Applicant v. The Pacific
  Lumber
• Company, Defendant, 2004 Cal. Wrk. Comp. P.D.
  LEXIS 90,
• Opinion Filed October 12, 2004
• WCAB found that there was insufficient evidence
  to establish the existence of an express
  agreement between defendant and lien
  claimant/medical provider fixing amounts to be
  paid for medical services, so as to remove the
  lien issue from WCAB jurisdiction under Labor
  Code Section 5304, when defendant was neither a
  claims payor, beneficiary, nor employer
  under the terms of lien claimants PPO contract
  and there was no privity of contract between the
  parties.

14
OBLIGATION TO PAY ACCORDINGTO THE FEE SCHEDULE

• Maria Molina, Applicant v. Best Western Park
  Place
• Inn, State Compensation Insurance Fund,
• Defendants, 2005 Cal. Wrk. Comp. P.D. LEXIS 19,
• Opinion Filed February 7, 2005
• , the WCAB has jurisdiction to resolve the fee
  dispute herein as the treatment in question was
  rendered to relieve or cure the applicant from
  the effects of an industrial injury. Further,
  SCIF was not a party to the agreement between BMC
  and Blue Cross. Thus, it is the opinion of this
  Court that SCIF has no standing to force the
  matter into arbitration.

15
Virginia Woodruff, Applicant v. Greenfield
Trucking, State Compensation Insurance Fund,
Defendants, 2007 Cal. Wrk. Comp. P.D. LEXIS 93,
Opinion Filed September 4, 2007

• Thus, it would appear that as a matter of public
  policy, that unless there is an absolutely clear
  and unambiguous agreement to the contrary, the
  OMFS amounts should apply. There is no clear and
  unambiguous agreement between the provider Good
  Samaritan and SCIF in this case. As such, all
  else being equal, the OMFS should prevail.
• The undersigned WCJ agrees with the general
  proposition asserted by Good Samaritan in its
  Response to SCIFs Petition for Reconsideration
  that there is no showing that SCIF has complied
  with the provision of Labor Code 4609 and that
  such a so called Silent PPO is statutorily
  prohibited. In this case, contrary to the
  provisions of Labor Code 4609, Blue Cross appears
  to have sold its PPO discount to SCIF in
  contravention of this labor code provision.

16
Virginia Woodruff, Applicant v. Greenfield
Trucking, State Compensation Insurance Fund,
Defendants, 2007 Cal. Wrk. Comp. P.D. LEXIS 93,
Opinion Filed September 4, 2007

• The term other payor as argued by the lien
  claimant is
• meant to refer to Blue Cross (card carrying)
  members,
• and there is no evidence that SCIF, an insurance
  company
• in and of itself was a member of Blue Cross or
  that
• applicant was a member of Blue Cross. SCIF or
  Blue
• Cross could have easily cleared up this ambiguity
  in the
• terms of the contracts by obtaining a
  contemporaneous
• addendum to the Blue Cross SCIF Agreement signed
  on
• behalf of Good Samaritan agreeing to be bound by
  the
• deep PPO discount. The parties failed to do
  this, leaving
• the ambiguous language in place. Obviously, Good
• Samaritan does not consider itself an other
  payor or it
• would not be litigating the matter. If the basic
  definition for
• a contract is that of a meeting of the minds
  between the
• contracting parties then no such meeting of the
  minds is
• demonstrated in this case.

17
Maria Molina, Applicant v. Best Western Park
Place Inn, State Compensation Insurance Fund,
Defendants, 2005 Cal. Wrk. Comp. P.D. LEXIS 19,
Opinion Filed February 7, 2005

• SCIF contends that paragraph 2.2 of the
  agreement
• between BMC and Blue Cross (Defendants Exhibit
  F) identifies SCIF as
• a party defendant to the agreement. No such
  language exists that
• specifically identifies SCIF as a party, nor did
  SCIF execute the
• agreement. SCIF contends that any dispute
  regarding payment of
• BMCs billings must be resolved via binding
  arbitration as set forth in
• the agreement between BMC and Blue Cross. As
  stated above, the
• WCAB has jurisdiction to resolve the fee dispute
  herein as the
• treatment in question was rendered to relieve or
  cure the applicant
• from the effects of an industrial injury.
  Further, SCIF was not a party to
• the agreement between BMC and Blue Cross. Thus,
  it is the opinion of
• this Court that SCIF has no standing to force the
  matter into
• arbitration.

18
LABOR CODE SECTION 4609 (Silent PPO)

• Virginia Woodruff, Applicant v. Greenfield
• Trucking, State Compensation Insurance Fund,
• Defendants, 2007 Cal. Wrk. Comp. P.D. LEXIS
• 93, Opinion Filed September 4, 2007
• The undersigned WCJ agrees with the general
  proposition
• asserted by Good Samaritan in its Response to
  SCIFs Petition for
• Reconsideration that there is no showing that
  SCIF has complied
• with the provision of Labor Code 4609 and that
  such a so called
• Silent PPO is statutorily prohibited. In this
  case, contrary to the
• provisions of Labor Code 4609, Blue Cross appears
  to have sold its
• PPO Discount to SCIF in contravention of this
  labor code provision.

19
LABOR CODE SECTION 4609 begins with the intent of
the code that being prohibiting the selling of
contract discounts

• a) In order to prevent the improper selling,
  leasing, or transferring of a health care
  providers contract
• SB 559, which is the bill that created Labor Code
  Section 4609
• in the Assembly Analysis as to the purpose of the
  bill, stated
• as follows
• Purpose of the Bill. The California Chiropractic
  Association and the California Health
• Care Association representing hospitals, are
  sponsors of this bill. The sponsors indicate
• the bill is designed to stop silent PPOs from
  inappropriately marketing and selling lists
• of provider panels that offer discounted rates.
  Preferred Provider Organizations
• (PPOs) are a type of managed care organization
  under which providers accept reduced
• payments in exchange for increased patient flow.
  Under these arrangements, individuals insured
• by a PPO plan are encouraged to use that plans
  preferred providers because the insurer pays
• a much higher proportion of the cost of service
  when it is rendered by a preferred provider.

20
LABOR CODE SECTION 4609

• The sponsors argue a silent PPO is created when
  the PPO gains
• additional revenue by selling its reduced
  provider rates to payors
• (e.g. insurers) who are not party to the
  preferred rate agreement
• with provider panels and who do not provide
  incentives for their
• beneficiaries to see these providers. These
  unauthorized discounts
• cost hospitals and physicians large amounts of
  money. In many
• instances, the bills sponsors assert that
  providers never intended to
• extend discounts to these additional payors and
  had no knowledge
• that their services had been sold. The sponsors
  argue this bill is
• necessary to reject such silent PPO efforts
  without the fear of
• contract termination.

21
LABOR CODE SECTION 4609

• The State of California and the former Governor
• of California has recognized that the improper
• selling of PPO discounts has cost the providers
• and the citizens of California millions of
  dollars
• every year. The American Medical Association
• case called the Silent PPO fraudulent. Most
• states, including California, have created laws
• specifically prohibiting this practice.

22
SILENT PPO- A SILENT PPO IS CREATED WHEN THE
PPO GAINS ADDITIONAL REVENUE BY SELLING ITS
REDUCED PROVIDER RATES TO PAYORS (I.E. WORK COMP
INSURERS) WHO ARE NOT PARTY TO THE PREFERRED RATE
AGREEMENT WITH PROVIDER PANELS AND WHO DO NOT
PROVIDE INCENTIVES FOR THEIR BENEFICIARIES TO
SEE THESE PROVIDERS
NO CONTRACT John Miranda, Jr., Applicant v. The
Pacific Lumber Company, Defendant, 2004 Cal. Wrk.
Comp. P.D. LEXIS 90, Opinion Filed October 12,
2004 WCAB found that there was insufficient
evidence to establish the existence of an express
agreement between defendant and lien
claimant/medical provider fixing amounts to be
paid for medical services, so as to remove the
lien issue from WCAB jurisdiction under Labor
Code Section 5304, when defendant was neither a
claim payor, beneficiary, nor employer
under the terms of lien claimants PPO contract
and there was no privity of contract between the
parties.
NO CONTRACT
JURISDICTION
JURISDICTION
Nico Zuniga, Applicant v. Herb Stewart, State
Compensation Insurance Fund, Defendants, 2002
Cal. Wrk. Comp. P.D. LEXIS 104, Opinion Filed
June 13, 2002 While SCIF may have been a
third-party beneficiary to the Blue
Cross/Cedars-Sinai Agreement in a Civil Code or
Commercial Code setting, they may not assert
such a right in a Workers Compensation case
where Labor Code Section 5304 applies. This
Labor Code section requires an express
agreement, whether oral or written, Between the
provider and the employer or carrier. This
provides a higher standard than civil or
commercial contract law.
Nico Zuniga, Applicant v. Herb Stewart, State
Compensation Insurance Fund, Defendants, 2002
Cal. Wrk. Comp. P.D. LEXIS 104, Opinion Filed
June 13, 2002 While SCIF may have been a
third-party beneficiary to the Blue
Cross/Cedars-Sinai Agreement in a Civil Code or
Commercial Code setting, they may not assert
such a right in a Workers Compensation case
where Labor Code Section 5304 applies. This
Labor Code section requires an express
agreement, whether oral or written, Between the
provider and the employer or carrier. This
provides a higher standard than civil or
commercial contract law.
FEE SCHEDULE
JURISDICTION
JURISDICTION
23
OBLIGATION TO PAY ACCORDING TO THE
FEE SCHEDULE Maria Molina, Applicant v. Best
Western Park Place Inn, State Compensation
Insurance Fund, Defendants, 2005 Cal. Wrk.
Comp. P.D. LEXIS 19, Opinion Filed February 7,
2005 , the WCAB has jurisdiction to resolve
the fee dispute herein as the treatment in
question was rendered to relieve or cure the
applicant from the effects of an industrial
injury. Further, SCIF was not a party to the
agreement between BMC and Blue Cross. Thus, it
is the opinion of this Court that SCIF has no
standing to force the matter into arbitration.
Maria Molina, Applicant v. Best Western Park
Place Inn, State Compensation Insurance Fund,
Defendants, 2005 Cal. Wrk. Comp. P.D. LEXIS 19,
Opinion Filed February 7, 2005 The language of
Labor Code Section 5304 is clear and
unambiguous. The WCAB has jurisdiction to
resolve all issues arising out of Labor Code
Sections 4600 to 4605 unless an express
agreement exists employer or carrier. No such
agreement exists between lien claimant and BMC.
Although, it may be argued that SCIF is a
third-party beneficiary to the agreement between
BMC and Blue Cross of California, Labor Code
Section 5304 requires an express agreement
between the medical provider and the
employer/carrier to remove jurisdiction from the
WCAB with respect to payment of fees for medical
treatment.
This case differs from the previous in that
it was a brokerage contract. The case stated
that since there were three contracts that was
sufficient to deny the WCAB of Jurisdiction. Sar
ah Waters, Applicant v. Los Angeles Clippers
Basketball Club, Inc. TIG Specialty Insurance
Solutions c/o Cambridge Integrated Services
Group, Inc., Defendants, 2005 Cal. Wrk. Comp.
P.D. LEXIS 15, Opinions Filed February 7, 2005
and April 26,2005 The background to this issue
is that CCN is in the business of preparing
contracts and referring patients to doctors or
hospitals, and there are other various aspects
of its business as well, and CCN entered into a
contract with Good Samaritan Hospital, under the
terms of which Good Samaritan Hospital would
accept for payment of medical treatment
according to a scheduled fee. Later on, CCN
entered into a separate contract with TIG.
JURISDICTION
LABOR CODE SECTION 4609 SILENT PPO CONTRACTS
24
Virginia Woodruff, Applicant v. Greenfield
Trucking, State Compensation Insurance Fund,
Defendants, 2007 Cal. Wrk. Comp. P.D. LEXIS 93,
Opinion Filed September 4, 2007 Labor Code
Section 5304 provides In this case, there is
no evidence of an express agreement between the
rendering institution, Good Samaritan Hospital
and the insurer State Compensation Insurance
Fund (SCIF). The only express agreements in
evidence are between Good Samaritan Hospital and
Blue Cross, and a separate agreement between
Blue Cross and SCIF. Two years separates the two
agreements. At best, SCIF is a third party
beneficiary, in a contractual sense, to the Good
Samaritan/Blue Cross agreement. Since there is
no express agreement between the institution
rendering treatment (Good Samaritan Hospital)
and the insurer (SCIF), the appeals board has
proper jurisdiction over the matter under Labor
Code section 5304.
LABOR CODE SECTION 4609 (Silent
PPO) Virginia Woodruff, Applicant v. Greenfield
Trucking, State Compensation Insurance Fund,
Defendants, 2007 Cal. Wrk. Comp. P.D. LEXIS 93,
Opinion Filed September 4, 2007 The
undersigned WCJ agrees with the general
proposition asserted by Good Samaritan in its
Response to SCIFs Petition for Reconsideration
that there is no showing that SCIF has complied
with the provision of Labor Code 4609 and that
such a so called Silent PPO is statutorily
prohibited. In this case, contrary to the
provisions of Labor Code 4609, Blue Cross
appears to have sold its PPO Discount to SCIF in
contravention of this labor code
provision. LABOR CODE SECTION 4609 begins with
the intent of the code that being prohibiting
the selling of contract discounts a) In order
to prevent the improper selling, leasing, or
transferring of a health care providers
contract SB 559, which is the bill that
created Labor Code Section 4609 in the Assembly
Analysis as to the purpose of the bill, stated
as follows
REVIEW COMPANIES
REVIEW COMPANIES
25
REVIEW COMPANY CUTS OFF BROKERAGE
CONTRACT Richard Balzano, Applicant v. City of
Los Angeles, PSI, Defendant, 2005 Cal. Wrk.
Comp. P.D. LEXIS 16, Opinion Filed April 13,
2005 The parties stipulated at trial that
Diversified is listed as a payor on CCNs
payor list. According sic the definition of
payor (supra), Diversified can only be
classified as such in the capacity of an
employer. They are not an insurance carrier,
health care service plan, non profit hospital
service plan,nor a governmental unit or any
other entity which has an obligation to provide
medical benefits to a beneficiary. Diversified
can be a payor only in so far as their own
employees (i.e. beneficiaries) are concerned.
Testimony at trial was that Diversified did not
pay any of the City of Los Angeles bills. They
merely provided bill review and discounts and
told the City of Los Angeles what they
recommended the City pay. The City of Los
Angeles actually paid the bills for medical
treatment in this case.
MORE ON REVIEW COMPANIES Susan Olsukka v. City
of Sacramento 2005 cql. Wrk Comp. P.D. LEXIS 27
Filed August 11,2005 It must be kept in mind
that it was defendant, not Cambridge, that
retained or authorized the services of lien
claimant in this case. The evidence indicates
an after-the-fact reduction by Cambridge based
on a contract, that was never offered into
evidence. Without this contract, the WCJ was,
and remains, unable to determine if lien
claimant agreed to be bound by the PPO price
any time an employer or carrier retained
Cambridge to review a bill.
Purpose of the Bill. The California
Chiropractic Association and the California
Health Care Association representing hospitals,
are sponsors of this bill. The sponsors indicate
the bill is designed to stop silent PPOs from
appropriately marketing and selling lists of
provider panels that offer discounted
rates. Preferred Provider Organizations (PPOs)
are a type of managed care organization under
which providers accept reduced payments in
exchange for increased patient flow. Under these
arrangements, individuals insured by a PPO plan
are encouraged to use that plans preferred
providers because the insurer pays a much
higher proportion of the cost of service when it
is rendered by a preferred provider. The
sponsors argue a silent PPO is created when
the PPO gains additional revenue by selling its
reduced provider rates to payors (e.g. insurers)
who are not party to the preferred rate
agreement with provider panels and who do not
provide incentives for their beneficiaries to
see these providers. These unauthorized
discounts cost hospitals and physicians large
amounts of money. In many instances, the bills
sponsors assert that providers never intended to
extend discounts to these additional payors and
had no knowledge that their services had been
sold. The sponsors argue this bill is necessary
to reject such silent PPO efforts without the
fear of contract termination.
26
The State of California and the former
Governor of California has recognized that the
improper selling of PPO discounts has cost the
providers and the citizens of California
millions of dollars every year. The American
Medical Association case called the Silent PPO
fraudulent. Most states, including California,
have created laws specifically prohibiting this
practice.
LABOR CODE SECTION 4609 (SILENT PPO CONTRACTS)
27
CONCLUSION

• This presentation is an attempt to show the
  participants a guide to
• understanding the PPO dilemma in California. With
  the use of flow
• charts and cases, the hope is that sufficient
  information has been
• presented to support the proposition that Silent
  PPOs are harming
• the providers and ultimately will harm society if
  the providers are unable
• or unwilling to treat Workers Compensation
  patients. Because of deep
• and severe discounts, the providers will be
  unable to afford to handle
• said patients.
• The presenters suggest that the providers look
  closely at all of their
• contracts and when negotiating, make certain that
  their contracts are
• not susceptible to the Silent PPO practice, as
  well as, contacting their
• legislatures, as other states have done,
  including but not limited to
• Texas, Louisiana, and Ohio. Laws have been passed
  in these states
• dealing specifically with the Silent PPO
  dilemma.
• The quickest and easiest solution to this
  problem would be that the
• patients provide a membership card at the time
  of treatment so that
• there will not be any surprises when the
  providers bill is paid.

28
REFERENCES

• Nico Zuniga, Applicant v. Herb Stewart, State
• Compensation Insurance Fund, Defendants, 2002
  Cal.
• Wrk. Comp. P.D. LEXIS 104, Opinion Filed June 13,
  2002
• Maria Molina, Applicant v. Best Western Park
  Place Inn,
• State Compensation Insurance Fund, Defendants,
  2005
• Cal. Wrk. Comp. P.D. LEXIS 19, Opinion Filed
  February 7,
• 2005
• Virginia Woodruff, Applicant v. Greenfield
  Trucking,
• State Compensation Insurance Fund, Defendants,
  2007 Cal. Wrk.
• Comp. P.D. LEXIS 93, Opinion Filed September 4,
  2007

29
REFERENCES

• Sarah Waters, Applicant v. Los Angeles Clipper
  Basketball
• Club, Inc., TIG Specialty Insurance Solutions c/o
  Cambridge
• Integrated Services Group, Inc., Defendants, 2005
  Cal. Wrk. Comp.
• P.D. LEXIS 15, Opinions Filed February 7, 2005
  and April 26, 2005
• Richard Balzano, Applicant v. City of Los
  Angeles, PSI,
• Defendant, 2005 Cal. Wrk. Comp. P.D. LEXIS 16,
  Opinion Filed
• April 13, 2005
• Susan Olsukka v. City of Sacramento 2005 cql.
  Wrk. Comp.
• P.D. Lexis 27 Filed August 11, 2005
• John Miranda Jr., Applicant v. The Pacific Lumber
  Company,
• Defendant, 2004 Cal. Wrk. Comp. P.D. LEXIS 90,
  Opinion Filed
• October 12, 2004

30
REFERENCES

• SB 559
• Labor Code Section 4609
• Labor Code Section 5304