Objection to PTP (California)

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Objection to PTP (California)

Postby lacompfun on Mon Sep 10, 2018 9:49 am

Scenario:

1. Applicant goes to PTP exam and sees Physician Assistant who issues a report.

Question:

1. If the defense objects to the Physician Assistant report is that valid?

IE does it literally have to be PTP for valid labor code 4062.2 objection?
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Re: Objection to PTP (California)

Postby LawAdvocate on Mon Sep 10, 2018 2:22 pm

The PA acts in place of the PTP and under the direct supervision of the PTP, otherwise the PA can't practice. It is a valid objection to the PTP and if you want to make it air tight, you can say we object to PA X, under the supervision of PTP Y, as to the following....
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Re: Objection to PTP (California)

Postby vampireinthenight on Tue Sep 11, 2018 8:15 am

Yeah, I agree. I usually just refer to the supervising physician. Just be sure to identify the report clearly. You could also refer to it as the report of the PA/PTP.
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Re: Objection to PTP (California) (California) (California) (Cal

Postby jpod on Tue Sep 11, 2018 9:00 am

what about the DWC's Bulletin No 00-01 from April 7, 2000?

Isn't there also a hurdle of CCR 9785 (a)(1) that a PTP is a physician who has examined the patient at least once?

here is the Bulletin:

The Division of Workers' Compensation has received an increasing number of inquiries concerning whether the use of Physician Assistants and Nurse Practitioners is permissible in workers' compensation cases. The Division of Workers' Compensation believes that Physician Assistants and Nurse Practitioners play a critical and fully authorized role in assuring that injured workers have timely access to high quality and cost effective medical treatment.

It is clear that no provision of the Labor Code prevents Physician Assistants or Nurse Practitioners, acting within the scope of their licensure, and under the appropriate degree of physician supervision, from providing medical treatment to injured workers.1 To the contrary, Labor Code Section 5307.1 provides, in pertinent part, that:

The administrative director shall include services provided by physical therapists, physician assistants, and nurse practitioners in the official (medical) fee schedule.. (Emphasis added.)

The Division believes that this provision clearly reflects the Legislature's recognition that Physician Assistants and Nurse Practitioners are necessary and fully authorized providers of medical care in the workers' compensation system.

The definition of "physician" in Labor Code Section 3209.3 expands the scope of the term "physician" to include additional medical practitioners such as acupuncturists, psychologists, and chiropractors who are not otherwise deemed "physicians" under the licensing laws covering doctors of medicine. This section does not bar Physician Assistants or Nurse Practitioners acting within the scope of their respective practices and under the appropriate physician supervision from providing treatment in workers' compensation cases.

The scope of practice for Nurse Practitioners is defined in Business and Professions Code Sections 2834 ¬ 2837, and the regulations in the California Code of Regulations. Provisions for supervision of Nurse Practitioners are required to be set forth in the standardized procedure guidelines as provided for in Business and Professions Code Sections 2725 and 2836.1 and Title 16, California Code of Regulations, Section 1474.

The scope of practice and supervision requirements for Physician Assistants are contained in Business and Professions Code Sections 3500 - 3546, and Title 16, California Code of Regulations, Section 1399.540 through 1399.571.

While Physician Assistants and Nurse Practitioners may treat injured workers, they may not determine or report on an injured workers' entitlement to benefits, including temporary disability. With respect to determining and reporting on an injured worker's entitlement to compensation benefits, Labor Code Section 4061.5 provides that:


The treating physician primarily responsible for managing the care of the injured worker or the physician designated by that treating physician shall, in accordance with rules promulgated by the administrative director, render opinions on all medical issues necessary to determine eligibility for compensation.
Title 8, Cal. Code of Regulations Section 9785, also provides that:

(c) The primary treating physician, or a physician designated by the primary treating physician, shall make reports to the claims administrator as required in this section.

(d) The primary treating physician shall render opinions on all medical issues necessary to determine the employee's eligibility for compensation in the manner prescribed in subsections (e) ,2 (f)3 and (g)4 of this section.
Under these Labor Code and regulatory sections, a "physician" is obligated to make and report on any medical decision that initiates, terminates or materially changes the injured worker's entitlement to any compensation as that term is defined in Labor Code Section 32075. Delegating the performance of these duties to a non-physician violates the obligations of a treating physician under both the Labor Code and Section 9785.
________________________________________

1The Labor Code and the Business and Professions Code can be found on the Internet at http://leginfo.legislature.ca.gov/faces/codes.xhtml. The California Code of Regulations can be found on the Internet at http://www.oal.ca.gov/.
2Doctor's First Report of Occupational Injury or Illness, (Form DLSR 5021).
3Progress and other interim reports.
4Permanent and stationary report.
5Labor Code Section 3207 provides that: "Compensation" means compensation under Division 4 and includes every benefit or payment conferred by Division 4 upon an injured employee, obligations of a treating physician under both the Labor Code and Section 9785.
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Re: Objection to PTP (California)

Postby vampireinthenight on Wed Sep 12, 2018 8:20 am

My recollection is that a nurse can extend TD but only for a number of days until the MD sees them.
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Re: Objection to PTP (California) (California)

Postby jpod on Thu Sep 13, 2018 7:41 am

Vampire:

One of the nurse practitioners I work with says that used to be the case but not anymore.

My questions is about PAs though. 1) Can a PA render opinions that affect entitlement to compensation even when the PTP co-signs the report? 2) Doesn’t the term “compensation” include both medical and indemnity benefits? My belief is the answer to the first question is NO and the answer to the second question is YES.

9785(D) says: The primary treating physician shall render opinions on all medical issues necessary to determine the employee's eligibility for compensation in the manner prescribed in subsections (e),2 (f)3 and (g)4 of this section.

9785(a)(1) says: The “primary treating physician” is 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.

The DWC seems to be saying while PA's can work under a contract that defines the scope the physician is allowing the PA to undertake per the B&P codes referenced in the DWC Bulletin (it appears there has be a written document outlining what the PA can do when acting in the shoes of the supervising physician) PA's are not "physicians” because PA's are not included in the definition of physician in LC 3209.3.

Next the Bulletin seems to say that not only does the PTP have to be a physician, but the physician cannot be a PTP unless that “physician” has examined the employee at least once.

Next the Bulletin says a “physician” who qualifies as a PTP cannot delegate the Duties of the Treating Physician to a non-physician b/c 9785(d) says only the PTP shall render opinions on all medical issues necessary to determine eligibility for compensation and that only a “physician” can " make and report on any medical decision that initiates, terminates or materially changes the injured worker's entitlement to any compensation as that term is defined in Labor Code Section 3207 (there appears to be a typo in the memo for this LC section reference).

All of this seems to mean that even if the PTP signs the PA’s report it cannot form the basis for initiating, terminating, or materially changing the workers’ entitlement to compensation b/c the PTP can only delegate that role to a physician not to a PA.

I don't think any of this affects the answer to the original post b/c LC 4062.5 says "at any time" but I am trying to understand if one can rely on a PA report co-signed by the PTP as the basis to terminate TTD or other "compensation".
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Re: Objection to PTP (California)

Postby vampireinthenight on Thu Sep 13, 2018 8:16 am

I always thought 3209.10(a) allowed the nurse to authorize 3 days of TD and that section is still there. I'm not sure what else that section would be referring to when it says "time off work".
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Re: Objection to PTP (California) (California)

Postby jpod on Thu Sep 13, 2018 9:54 am

The NP I work with says that 3 days was allowed b/c no TTD is due and payable during the 3 day waiting period. TTD is not due for the first three days unless hospitalized or the period off work extends for 14 days (or more than 14, I can't recall).

Note that the section only authorizes a NP/PA to authorize the patient to receive "time off from work for a period not to exceed three calendar days". There is no reference to TTD. Plus section b says it is not he intent of the Legislature that the requirement (above) apply(ies) to any other section of the law or to any other statute or regulation.

What about my PA, MD, PTP question?

Anyone?
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Re: Objection to PTP (California) (California)

Postby vampireinthenight on Fri Sep 14, 2018 7:49 am

1) Can a PA render opinions that affect entitlement to compensation even when the PTP co-signs the report?


Not sure what you mean by affect. It would be easier to answer a specific scenario. But in theory I would agree with you. I think an award of compensation would need a physician evaluation and could not be solely based on a nurse eval.

The NP I work with says that 3 days was allowed b/c no TTD is due and payable during the 3 day waiting period. TTD is not due for the first three days unless hospitalized or the period off work extends for 14 days (or more than 14, I can't recall).


I guess it could be read that way. Why does your NP come to that conclusion? It seems pretty lame to have a WC statute that doesn't relate to compensation. You don't need 3209 to use your own sick leave for 3 days.
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Re: Objection to PTP (California)

Postby jpod on Fri Sep 14, 2018 9:55 am

Vampire:

I am not concerned with NP; I am concerned about physician assistants. As to 3209 notice it does not use the term compensation, it uses time off work. I suspect this is so b/c the first 3 days of lost time are not compensable; hence taking someone off work for 3 calendar days is not issuing a report that entitles anyone to "compensation".

What I am asking is if a PA issues a medical report that is cosigned by either an MD or the PTP is it true that report CANNOT form the basis for terminating compensation (medical or indemnity benefits)? The DWC Bulletin appears to say it cannot:

"...(d) The primary treating physician shall render opinions on all medical issues necessary to determine the employee's eligibility for compensation in the manner prescribed in subsections (e) ,2 (f)3 and (g)4 of this section.
Under these Labor Code and regulatory sections, a "physician" is obligated to make and report on any medical decision that initiates, terminates or materially changes the injured worker's entitlement to any compensation as that term is defined in Labor Code Section 32075. Delegating the performance of these duties to a non-physician violates the obligations of a treating physician under both the Labor Code and Section 9785...".

It seems to me cosigning can not cure the the issue highlighted in paragraph (d) because that would be delegating the duties of the PTP to a non-physician. Or is it that cosigning means it was not delegated?

Example: if you depose a PA who issued a report that was co-signed and asked: who formed the opinions in this report? Did you create/form the opinions contained therein and have the report co-signed by your supervising physician? Did your supervising physician examine the employee at least once?

If the answers are: Yes I formed the opinions and forwarded the report to my supervising MD to co-sign; No the my supervising physician never examined the employee.

If that is the case DWC seems to be saying that report is not a report issued by the PTP; and the MD can not be the PTP b/c they never examined the employee. And of course the report can not be used to initiate, terminate etc entitlement to compensation (medical and indemnity).
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