Role of former PTP (California) (California) (California)

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Role of former PTP (California) (California) (California)

Postby theAxe on Tue Apr 07, 2009 8:31 am

Scenario #1:
1. Accepted injury - WC industrial clinic sends IW to specialist.
2. IW obtains atty who selects different PTP w/consulting specialist.
3. Panel QME is obtained to resolve IC disputing necessity of surgery, Panel QME agrees on need for surgery.
3. DA refers all new PTP repts to former PTP who opines and disagrees with all current PTP tx and conclusions with no further exam - and now calls himself the QME.

Scenario #2:
1. Denied injury - IW obtains atty who selects PTP who describes injury as compensable and commences tx.
2. Expidited hearing determines injury is compensible.
3. IC pulls tx from PTP and forces pt into MPN for tx.
4. AA wants former PTP to review and comment on treatment and conclusions of new PTP.

Edited to add Date of Injury 12/2005

Question: Does the former PTP have any admissable role once the PTP hat has passed from them?
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Re: Role of former PTP (California) (California) (California)

Postby steelmanlaw on Mon Apr 13, 2009 10:07 am

4062.3 (k) may be instructive: no disputed issued may be the subject of a DOR "unless there has first been an evaluation by the treating physician or an agreed or qualified medical evaluator." "the" in reference to treating physician implies present tense. However, at least the earlier reports issued when the former PTP was PTP should be admissible. As to followups after the PTP hat is passed, nothing in the Labor Code that I can find precludes clarification by the former PTP at any time. The party asserting the old PTP's opinion on a new issues might want to rely on the fact that that PTP has something of relevance and materiality to offer. However, we are dealing with latent ambiguities in the Code, which are partly a result of a number of revisions over the years. An older version of 4062 made it clear that reports not obtained per section 4062 are not admissible, except that THE treating physicians' report is always admissible.

Therefore, you are in an area which requires use of advocacy, depending on which side of the issue you come down. I don't think the Board should exclude a report from a prior PTP just because he is "former". In Sum, there is not mandatory language either way that I find in the Labor Code on your issue.
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Re: Role of former PTP (California) (California) (California)

Postby theAxe on Tue Apr 14, 2009 9:12 am

Thank you for your response.

I work with a multi-physician, multi-specialty medical group (PTP, QME, AME) and we are seeing an increase in both scenarios and mostly get paid for scenario #1 but never for scenario #2. I too did not see any support in the Labor Code for such a role for the "former PTP" and recalled the older version of 4062 that as you point out, made it clear that reports not obtained per section 4062 are not admissible, except that THE (meaning actual current) treating physicians' report is always admissible.

We are routinely told that with post 1/1/05 DOI, the MD can only wear one of three hats and get paid: the PTP(meaning the actual current properly designated), the Panel QME, or the AME (and of course properly designated secondary consultations under each category), and that any other reporting done simply is not recognized in the claims file - unless, of course the IC is the requesting party -

Clearly the PTP reports from the time the PTP was providing treatment would be admissible. I don't see any way the "former PTP" could become the "DQME" on a post 1/1/05 DOI, as portrayed in Scenario #1; do you? Would these reports be Med/Legal or something else?

Even if there is sufficient advocacy to get the "former PTP" reports from Scenario #2 to be admissable in court, is there any legal support for obtaining payment for same? If not, how is it that the defense (holding the purse strings) can obtain a "second bite" as it were, while the IW cannot (unless they wish to pay out of pocket -unlikely- and not be reimbursed)?
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Re: Role of former PTP (California) (California) (California)

Postby postscript2 on Tue Apr 14, 2009 2:46 pm

The "defense" can call the original PTP anything it wants to but it is certainly not a viable DQME! They can obtain an evaluation or reports if they want under 4050, but that doesn't mean that they are admissible.

It's either the PQME or an AME process, in both cases to resolve disputes. Unusual that you didn't mention U.R. (that's a first) ;)

I call it the "back door process," so that different opinions, while perhaps may or not be admissible under other circumstances and standing alone, can then be passed along to a PQME or an AME later, which if incorporated in the report as part of the "medical review" could be construed as evidence either way.

I don't like this practice. It happens all of the time, as you well know by now. What I don't understand is why your DR's are not getting paid? Maybe I'll have to re-read your post again...

Good luck!

LCS :)
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Re: Role of former PTP (California) (California) (California)

Postby theAxe on Wed Apr 15, 2009 7:48 am

Hi PS,
I didn't bring up UR as that was not part of the question regarding the role of former PTPs - however, in Scenario #1 you're right, UR was the first level denial for a hand surgery - it was done by a chiropracter, on appeal it was then denied by a general surgeon. Then they turned the former PTP into a DQME, and finally a Panel QME was obtained who approved the need for surgery over a year of TTD later - leaving very limited TTD time for the patient to recover from surgery solely due to the delay/deny tactics of the IC - but that's another issue.

I figured the former PTP reports were an attempt at the "backdoor" process you describe, and there are those who say that this is reasonable and fair, as "both sides" can get their own reports at their own cost, but most IWs are struggling to make ends meet to put food on the table and a roof over the heads of their family with diminished income while trying to recover from their injuries and attempting to understand the bizarre and complex system we call workers' comp, whereas the IC $$s, while a sociatial cost, will not take food out of the mouth's of anyone's children.

My docs are getting paid if the IC requests the former PTP record review, but the IC states they have no obligation for payment if the same type of report requested by the IW or their atty.

My question remains: if the former PTP's rept. reviewing and commenting on the current PTP's treatment plan, which was requested by the IW or their atty. is accepted as admissable by the WC judge or used in the determination of a PQME or AME, is there any support for or obligation for payment by the IC?
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Re: Role of former PTP (California) (California) (California)

Postby postscript2 on Wed Apr 15, 2009 12:54 pm

Well, in this case you'd have to get creative. It's an unfortunate situation, and really puts the doctor in an awkward position when the I/W or A/A requests such an evaluation.

I've a few suggestions, but no LC to specifically back it up (YET):

1) Have the doctor send a written request to the I/C seeking authorization prior to the records review. Make sure the auth is returned in writing-verbal won't hold water...

2) If the report was incorporated into a PQME or AME and a judge issued a decision based upon it, I'd say it's worth challenging in court if the I/C won't anty up.

3) File a lien; it can't hurt and at least you may recover something.

4) I'd use the arguement that since the I/C had their second opinion, the A/A should be able to obtain a rebuttle as well--otherwise it's a one way street (which is usually the case).

The problem is that your thought process is very rational in an irrationale system! I know this from being on both sides of the fence; over 20 years in the business. I wish I had more to offer you. Better safe than sorry though,

LCS ;)
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Re: Role of former PTP (California) (California) (California)

Postby steve appell on Wed Apr 15, 2009 3:31 pm

"if the former PTP's rept. reviewing and commenting on the current PTP's treatment plan, which was requested by the IW or their atty. is accepted as admissable by the WC judge or used in the determination of a PQME or AME, is there any support for or obligation for payment by the IC?"

The answer is no.
There is no rule, reg, case or statute law that indicates anything admissable is compensable.
There is no rule, reg, case or statute law that indicates anything reviewed by and/or relied on by the AME/QME is compensable.
Reports that have a false history & reports that do not have a logical cause effect nexus are only 2 of many examples how an admissable report may not be compensable.

In fact, the defense in this case might very well want to argue that the report is not compensable simply because it is not treatment that helped cure or relieve the applicant from the industrial injury.

After all, isn't that the standard for payment to a treating "errrrrrrrr" former treating doc?
Steve

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6311 Van Nuys Bl #480
Van Nuys, Ca 91401
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Re: Role of former PTP (California) (California) (California)

Postby stewshe@comcast.net on Wed Apr 15, 2009 3:51 pm

LCS,

The "back door process" you mentioned in your post yesterday has been more or less officially disapproved in the 2/17/09 QME Regs, CCR §§1 - 159, with an exception. The following is an entry I've added for the summer 2010 edition...assuming it isn't amended futrher by then:

<<
* Medical records including prior treatment: 2/09 CCR
§35(a)(2), but 35(e) prohibits having a “consult” sent
to PTP to comment upon and then claim that consult
should be considered part of the treatment record
when the consult is really inadmissible; discussed at
pages 27-28 of “Final Statement of Reasons,” noting a
WCJ may rule it is admissible, allowing it to be sent
>>

I would think obtaining the opinion of a prior treater would perhaps qualify as such a "consult" if the new treater commented upon it....and if a WCJ decides to admit it? I doubt most would, but again it would depend on the facts.

A lot of strange things can be admitted into evidence. I recall one EE who INSISTED on telling the judge about cash he had been paid "under the table" for years! The defense attorney objected, since there was no proof, but the WCJ admitted it into evidence and said he found it "compelling" and undoubtedly true, explaining this was an "admission against interest," because he awarded TD/PD based on the testimony as to the EE's true AWW and then copied the IRS with his decision!
Stew (James T. Stewart)
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Re: Role of former PTP (California) (California) (California)

Postby rbaird on Thu Apr 16, 2009 12:05 pm

Reminds me of the time when I represented the boyfriend in a non-marriage Marvin case. Both boyfriend and girlfriend worked in a restaurant. Girlfriend wanted money after boyfriend dumped her. Both admitted to stealing from the employer. I let my guy testify at deposition, even tho' potentially incriminating to the IRS, because I knew girlfriend could not spill the beans and profit from her theft. Sounds like a savvy judge.
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