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Reduced and Denied Health Insurance Claims

10/29/2009
Carlin Phillips
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Silent PPOs in CA Workers Comp?

There has been a battle brewing in California over whether Silent PPO discounts are being taken on certain workers compensation medical claims.  In these types of cases, there is always the threshold question of what court hears the case because, as a general rule, unpaid work related medical bills are typically adjudicated by a workers compensation court.  If a challenge is brought in a workers compensation court, which is typically an administrative court, the court first decides whether it has jurisdiction, i.e. the authority, to hear such a dispute because it involves delving into private contracts between medical providers, PPOs and insurers, something usually left to a court of more general jurisdiction.  If the workers compensation court exercises jurisdiction, it then analyzes whether PPO discounts can be applied under the state's workers compensation laws.  Sometimes the state workers compensation laws address PPO discounts and sometimes they are silent on the issue (no pun intended).  For any court to get its hands around this issue, it will invariably have to examine the PPO contract between the medical provider and the PPO, whether there is any kind of relationship between the provider and the insurer taking the discount and whether there were any steerage mechanisms in place to get the injured worker to the provider's office.

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13 Ventura Drive
North Dartmouth, MA 02747
Toll Free: (877) 892-5620