to obtain from their claims
adjuster in the process of their worker’s compensation investigation is the:
Within five days of an injured worker's initial medical
examination, for every occupational injury or illness, the injured worker's
Primary Treating Physician, hereafter referred to as the PTP must complete and
issue this form. If the injured worker changes their PTP, their new PTP
will also need to complete this form. The PTP must then send two copies
of this report to the employer's workers' compensation insurance carrier
or their worker’s compensation claims administrator. If the physician
fails to file a timely report it may result in assessment of a civil penalty
against the physician.
The PTP is defined in the California Code of Regulations
Title 8 Section 9785(a)(1) as, "the physician who is primarily responsible
for managing the care of an employee, and who has examined the employee at
least once for the purpose of rendering or prescribing treatment and has
monitored the effect of the treatment thereafter." This PTP is the
sole physician who is responsible for determining the injured worker’s
disability status and managing the medical treatment. A further
description of the duties of the PTP can be found Title 8 CCR Section 9785.
The PTP can initially be selected by the employer, usually
the physician at their designated industrial condition. This is
especially the case if the injured worker has not pre-selected their own
personal physician prior to the date of the injury or the onset of illness.
If the injured worker has not predesignated their own
personal physician to treat them in case of a work related injury and their
employer has a State approved Medical Provider Network
(MPN) in place, then the injured worker is required to treat with a
physician within the Medical Provider Network. If by chance the injured
worker’s personal regular physician is in the MPN then the worker may select
their physician.
Now we come back to the form itself. The form is
divided into twenty-seven sections. The first twenty-six sections are
numbered. The final section has the doctor’s information and
signature. There is a wealth of information that can be obtained from a
careful review of this document by the investigator. This information can
refute or corroborate other information obtained through your
investigation. While all the information may be important, I suggest the
investigator focus on sections 5 through 26. In these sections, you will
uncover what the injured worker told the doctor, the date of time of the
injury, where they were injured and how they were injured. In box
16, the medical provider has to disclose whether or not they have treated the
injured worker before. Box 17 will list the injured worker’s subjective
complaints (i.e. pain, numbness, dizziness, etc.). Boxes 18 – 24 list the
physician’s findings on their examination of the injured worker. Things
like objective findings (i.e. loss of range of motion, x-ray or MRI results,
laboratory results, etc.), the physician’s diagnosis including assigned ICD-9 Diagnosis Codes, and
whether or not the physician in his opinion feels that the diagnoses rendered
are consistent with injured worker’s account of the injury. Thereafter,
the physician must disclose if there are any current conditions that will
impede or delay the injured worker’s recovery from their work injury.
This is a place where the physician may disclose a non-work related condition
such as diabetes, a condition which often slows down an injured worker’s
recovery from an injury. The physician then is to describe what treatment
was rendered during the office visit (box 23) and then advise if any further
treatment is recommended to cure or relieve the effects of the injury or
illness (box 24). In box 26, the physician has to provide the injured
worker’s work status (the injured worker’s ability to return to work).
The physician will indicate if the worker is able to return to their regular
job or whether or not temporary work restrictions are necessary and what those
restriction are. If the injured worker is not capable of returning to any
work at the time of the evaluation, the physician will likely just write in
this section either “off work” or “TTD” which means Temporary Total
Disability. Finally, the physician must sign the report, type or print
their name and address and their degree (MD, DO, DPM, etc.), their medical license
number, their Federal Tax Identification number, and their office or direct
telephone number.
As a side note, the more claimant profile and
background that you provide to the assigned adjuster/examiner regarding the
claim you are investigating, the better their estimate will be for the
claim’s reserves or the money that an adjuster
allocates to a claim file for reasonable anticipated benefit and/or expense
payments on that file. This will make the actuaries, the employer’s, the
insurance companies, and the state regulatory agencies happier when a claim is
properly adjusted according to the principle of anticipated probable financial
outcome.
If you have any questions or comments about the information contained in this blog, you can enter it in the section at the end of the post that says "Post A Comment." If you have any ideas about future topics you can e-mail them to me directly at GetTruth@precisiondetective.com.
Please feel free to share this information with your friends or colleagues.
Stay tuned for the next installment of this California Worker's Compensation series by
The Precision Detective
