It Takes a Village (for a Workers’ Comp Claim)

Work Comp physicians have a lot to take care of when they’re conducting an appointment with a patient. Once the appointment is over, the physician doesn’t simply hang up his stethoscope and go home. Oh no. There is much more work to be done.

The physician and their posse

Before going on, it’s important to remember that very few workers’ compensation physicians only see workers’ comp patients. Many who act as PTPs (Primary Treating Physicians) also work as Primary Care Physicians, Orthopedists, etc.

A primary care physician needs to see the patient, assess, and treat their injury. The work comp PTP will do all of these, along with an entire workload of other tasks. Since Primary Care Physicians already require a staff for their own clinics, it’s easy to see that a PTP will need their own staff, even one that’s considerably larger (could be 20 people, or more!), to handle the following:

  • Writing the necessary work comp reports. California reports include:
  • Communicating with the employers’ insurance via:
    • Telephone, meaning:
      • Long hold times,
      • Missed calls,
      • People being out of the office
      • People no longer working at the office
    • Fax, meaning:
      • Preparing documents to send
      • Collecting related documents
  • Scheduling appointments with patients, which includes:
    • Working with the patient’s Nurse Case Manager to coordinate an appointment time

This list doesn’t even take into account other factors, like communicating with attorneys in the event of a deposition or greater legal entanglements.

We have spoken at length in the past about how a physician stands to profit from starting a work comp clinic, but when the office does not have a strong staff to assist the PTP with these tasks, workers’ compensation clinics often lose money, when the goal is to be profitable.

Missed Connections

Even with a full staff, a workers’ comp clinic relies on the MPN (Medical Provider Network) to connect the patient to the clinic.

Ideally, an MPN is a list of doctors within a certain region who have a contract to work with a workers’ comp insurance company. The insurance company receives a call from the employer that an employee has been injured. The insurance company will then reach out to a provider within the network, in a nearby area to the business where the employee was injured.

We say ideally because the insurance company often has difficulty finding a provider due to many factors. These include:

  • Network lists that need to be updated.
    • An example would be, the insurer contacts an in-network clinic, to have the clinic secretary inform the insurer that their clinic no longer takes workers’ comp patients, and hasn’t for years
  • No clinics in the employer’s region
  • Difficulty getting in touch with the clinic (Stakeholders having difficulty reaching one another is a common theme, and huge problem in workers’ comp)

In California, all of the above happen quite often.

“The Dark Underworld of Third-Party Vendors”

Carrying on with the overarching theme of stakeholders spending long amounts of time on the phone, a form of business has come up as a means to address the issue: Third-Party Vendors. These third party vendors arrange for communication between stakeholders (The PTP and insurance, or the PTP and specialist, the insurance and the employer), or books appointments for the patient when necessary.

Of course, the existence of these third party vendors doesn’t mean that stakeholders magically start picking up the phone.  In fact, quite the opposite. Third party vendors have the same trouble getting in contact with the stakeholder that the PTP, or insurance, or the employer does. To make matters, worse, it can be difficult for the stakeholder to reach the third-party vendor! So now there’s more waiting, which may result in one stakeholder reaching directly out to the other anyway!


Work comp can be made easier by having more people in certain areas. More staff in the office means better communication with stakeholders. More workers’ comp PTPs in a network means more available service for the injured workers in the area.

Though, adding more people in other areas can lead to disaster. For example, the above mention of third-party vendors further complicating communication between stakeholders.

The key to conducting a workers comp claim smoothly (at least, as smoothly as possible), is when there are the right number of people performing the right tasks to get the patient the treatment they need, that all stakeholders can agree upon.

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