Primary Treating Physicians and Workers’ Compensation: What You Need to Know

What is a Primary Treating Physician? Why is it important?

A Primary Treating Physician plays an important role for an Injured Worker in the handling of their worker’s compensation claim. A Primary Treating Physician has the power to issue reporting which can trigger the acceptance of a claim for compensation and entitlement to benefits. Primary Treating Physician are called upon to make “medical determinations” which impact variety of medical/legal issues.

What is the Role of a Primary Treating Physician?

The “Primary Treating Physician” is the physician who is primarily responsible for managing the care of an Injured Worker. The PTP is someone who has examined the injured worker at least once for the purpose of rendering or prescribing treatment and has monitored the effect of the treatment thereafter.

Also, the Primary Treating Physician shall be responsible for obtaining all of the reports of secondary physicians and shall, unless good cause is shown, within 20 days of receipt of each report incorporate, or comment upon, the findings and opinions of the other physicians in the Primary Treating Physician’s Report.

Further, Secondary Physicians, Physical Therapists, and other health care providers to whom the employee is referred shall report to the Primary Treating Physician in the manner required by the Primary Treating Physician.

Who can choose the Primary Treating Physician?

Both the Injured Worker and the Employer/Claims Administrator, at certain points in time, can select the Primary Treating Physician.

Can I choose a Chiropractor as a Primary Treating Physician?

Yes. A Chiropractor can be chosen as the Primary Treating Physician. There are some limitations, however. For injuries on or after January 1, 2004, a chiropractor shall not be a primary treating physician after the employee has received 24 chiropractic visits, unless the employer has authorized additional visits in writing. This prohibition shall not apply to the provision of postsurgical physical medicine prescribed by the employee’s surgeon, or physician designated by the surgeon pursuant to the postsurgical component of the medical treatment utilization schedule adopted by the Administrative Director pursuant to Labor Code section 5307.27. For purposes of this subdivision, the term “chiropractic visit” means any chiropractic office visit regardless of whether the services performed involved chiropractic manipulation or were limited to evaluation and management.

primary physicians in workers comp cases

What is a Secondary Physician?

A “Secondary Physician” is any physician other than the Primary Treating Physician who examines or provides treatment to the employee, but is not primarily responsible for continuing management of the care of the employee.

The rules are different for Chiropractors. For injuries on or after January 1, 2004, a chiropractor shall not be a secondary treating physician after the employee has received 24 chiropractic visits, unless the employer has authorized, in writing, additional visits. This prohibition shall not apply to the provision of postsurgical physical medicine prescribed by the employee’s surgeon, or physician designated by the surgeon pursuant to the postsurgical component of the medical treatment utilization schedule adopted by the Administrative Director pursuant to Labor Code section 5307.27. For purposes of this subdivision, the term “chiropractic visit” means any chiropractic office visit regardless of whether the services performed involved chiropractic manipulation or were limited to evaluation and management.

What are “Medical Determinations” and Why are They Important?

A “Medical Determination” means a decision made by the Primary Treating Physician regarding any and all medical issues necessary to determine the employee’s eligibility for compensation. Such issues include, but are not limited to, the scope and extent of an injured worker’s continuing medical treatment, the decision whether to release the injured worker from care, the point in time at which the injured worker has reached permanent and stationary status, and the necessity for future medical treatment.

What happens when treatment ends from the Primary Treating Physician?

A Primary Treating Physician, when ending treatment, will make a “release from care.” This is a determination by the Primary Treating Physician that the injured worker’s condition has reached a permanent and stationary status with no need for continuing or future medical treatment.

What is “Continuing Medical Treatment”?

“Continuing Medical Treatment” is occurring or presently planned treatment that is reasonably required to cure or relieve the injured worker from the effects of the injury.

What is “Future Medical Treatment”?

“Future Medical Treatment” is treatment which is anticipated at some time in the future and is reasonably required to cure or relieve the injured worker from the effects of the injury.

What is “Permanent and Stationary Status”?

“Permanent and Stationary Status” is the point when the injured worker has reached maximal medical improvement, meaning his or her condition is well stabilized, and unlikely to change substantially in the next year with or without medical treatment.

Can I have more than one Primary Treating Physician?

No. An employee shall have no more than one Primary Treating Physician at a time.

Can I can change Primary Treating Physicians?

Yes. You can designate a new Primary Treating Physician of your choice pursuant to Labor Code Section 4600, or 4600.3. It can be done if there is a need for continuing medical treatment or future medical treatment.

When can I change Primary Treating Physicians?

You may designate a new Primary Treating Physician to render future medical treatment either prior to or at the time such treatment becomes necessary.

Can Medical Determinations of the Primary Treating Physician be disputed?

Yes. Both parties may dispute the determinations.

If the claims administrator disputes a medical determination made by the Primary Treating Physician, the dispute shall be resolved under the applicable procedures set forth at Labor Code sections 4060, 4061, 4062, and 4610.

If the injured worker objects to a decision made pursuant to Labor Code section 4610 to modify, delay, or deny a treatment recommendation, the dispute shall be resolved by independent medical review pursuant to Labor Code section 4610.5, if applicable, or otherwise pursuant to Labor Code section 4062.

What Opinions are the Primary Treating Physicians has to address?

The primary treating physician shall render opinions on all medical issues necessary to determine the employee’s eligibility for compensation

What is a Doctor’s First Report?

After the initial examination, within 5 working days following initial examination, a Primary Treating Physician shall submit a written report to the claims administrator on the form entitled “Doctor’s First Report of Occupational Injury or Illness. On line 24 of the Doctor’s First Report, or on the reverse side of the form, the physician shall (A) list methods, frequency, and duration of planned treatment(s), (B) specify planned consultations or referrals, surgery or hospitalization and (C) specify the type, frequency and duration of planned physical medicine services (e.g., physical therapy, manipulation or acupuncture).

What are the type of issues that Primary Treating Physicians are to address?

Primary Treating Physicians are to address the following matters: (1) If the employee’s condition undergoes a previously unexpected significant change; (2) If there is any significant change in the treatment plan reported, including, but not limited to, (A) an extension of duration or frequency of treatment, (B) If there is a new need for hospitalization or surgery, (C) If there is a new need for referral to or consultation by another physician, (D) If there is a change in methods of treatment or in required physical medicine services, or (E) If there is a need for rental or purchase of durable medical equipment or orthotic devices; (3) If the employee’s condition permits return to modified or regular work; (4) If the employee’s condition requires him or her to leave work, or requires changes in work restrictions or modifications; (5) If the employee is released from care; or (6) If there is the conclusion that the employee’s permanent disability precludes, or is likely to preclude, the employee from engaging in the employee’s usual occupation or the occupation in which the employee was engaged at the time of the injury.

Can the Claims Administrator request additional information from the Primary Treating Physician?

Yes. The claims administrator may reasonably request appropriate additional information that is necessary to administer the claim.

How is Treatment requested?

Treatment is requested by a written request for authorization of medical treatment for a specific course of proposed medical treatment, or a written confirmation of an oral request for a specific course of proposed medical treatment, must be set forth on the “Request for Authorization,” DWC Form RFA, contained in section 9785.5. A written confirmation of an oral request shall be clearly marked at the top that it is written confirmation of an oral request. The DWC Form RFA must include as an attachment documentation substantiating the need for the requested treatment.

What happens when a Primary Treating Physician renders an Injured Worker Permanent and Stationary?

When the Primary Treating Physician determines that the Injured Worker’s condition is permanent and stationary, the physician shall, unless good cause is shown, report within 20 days from the date of examination any findings concerning the existence and extent of permanent impairment and limitations and any need for continuing and/or future medical care resulting from the injury.

Does a Primary Treating Physician have an obligation to issue a report concerning the voucher?

The Primary Treating Physician, upon finding that the injured worker is permanent and stationary as to all conditions and that the injury has resulted in permanent partial disability, shall complete the “Physician’s Return-to-Work & Voucher Report” (DWC-AD 10133.36) and attach the form to the report required under subdivision (h).

If you would like a “free” consultation with a workers compensation attorney, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. They have been helping people in Central and Southern California deal with their worker’s compensation cases for 25 years. Contact us today for more information.

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