Dr. John Alchemy and Cory Oleson discuss the PTP (Primary Treating Physician)’s central role in a workers’ compensation claim, and the pitfalls of communication between stakeholders.
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What Primary Treating Physicians Actually Do In Worker’s Compensation Pt. 1
Cory Oleson (Host): Welcome back to the California Worker’s Comp Report. It’s Tuesday, December 1, 2021 and today Dr. John Alchemy and me, Cory Oleson, discuss the topic: What do primary treating physicians actually do in worker’s compensation?
Alright, we are back in the studio and today we are talking about what primary treating physicians actually do in worker’s compensation. I’m here with Dr. John Alchemy today. How are you, John?
Dr. John Alchemy: Hey, Cory! We’re back again. I’m doing fine.
Cory: We have a blog, which we always mention at the end of our episodes, and we have formally written one blog post called “Worker’s Compensation Ethic: The Duty of the Physician in Worker’s Compensation.” And we outline that the roll of a physician is to be, as John has put it previously, the quarterback of the injury in the worker’s compensation claim. We outline a lot of what a PTP does, a primary treating physician for worker’s compensation claims does, but they do a lot more than that. But I guess we will start with the absolute basics. And John, what is a PTP?
Dr. John Alchemy: Yeah, we’ve written about this before and looking over prior what we’ve touched on this topic it’s been more of a legal, administrative responsibility of the PTP, and what I really wanted to get out of this podcast series is what is the primary treating physician really doing? And how do we better understand his or her role in taking care of patients and actually navigating the system in real time as opposed to what the book says they do. Versus what they really do, and how well it gets done or how well it does not get done.
So I think we will touch again – the primary treating physician is the quarterback of the claim, absolutely. And that’s really the centerpiece of a work comp claim. And although there is some treating and diagnosing that goes along with that, there’s also a lot of administrative systems that that primary treating physician has to have at their disposal to get the system to work. And that’s why some people have better experiences with work comp than others, because if you don’t have the infrastructure in place – and this is where I think a lot of people don’t understand work comp is one of the heaviest administrative lifts of all medical specialties, just because paperwork and intermediary peer reviews going on, and authorizations. Calling and scheduling. It’s amazing and it’s not unusual for one primary treating physician to have a support staff behind the scenes of 20 people to make this happen.
So you wonder why people don’t want to do work comp, it’s because you have to have an amazing infrastructure in your office to do this and it has to work and be efficient. Otherwise it’s more expensive for you to see patients than to make any money to support the practice so you can stay open to take care of them. This is a real problem and that’s why we can’t find people to do work comp, you certainly can’t have a practice that’s a little work comp, because you might as well have a lot of work comp, because you have to have the same infrastructure in place and the same people whether you’re seeing one patient or fifty. So it’s a real challenge and I really don’t think a lot of people, including the insurance companies, understand what’s at stake here to have a successful management of a work comp claim.
Cory: Absolutely. Going back once again to the previous article that we did – we had a long article just explaining the basics of the description that the PTP might do. Which by the way, just for ultimate clarification, just for anybody that might be listening that knows nothing about the work comp system, welcome, and the PTP is the doctor that sees the injured patient at the most basic levels.
This podcast covers the additional duties on top of all of the in office duties. When we refer to the work comp system we are referring to a system that is comprised of many people, departments, and interests. You have an employer and employee, the insurance involved, the entire state department like the DIR (Department of Industrial Relations) and the DEU (Disability Evaluation Unit) and the DWC (Department of Worker’s Compensation). And in the middle of all this you have the injured worker, but the injured worker isn’t the one handing out all the information and taking all the measurements, that’s the PTP.
So, John, the next question being how is the system structured around PTPs with networks?
Dr. John Alchemy: Well when a patient comes to see a doctor, particularly if they’ve never been in the system before, they have no idea how to navigate this and totally dependent on the PTP to lead them through this maze of treatment, authorization, recovery, all these things. And the system in general is scheduled with an insurance company of some type that has networks of all kinds of things. Anything you can think of that would require treatment or durable medical equipment like a cane or a splint, medications, anything that requests a determination of medical appropriateness of medical necessity. It all goes through one system or another that they’ve set up.
It’s the access to these systems and knowing how to get the request for treatment, surgery, physical therapy, medications – understanding how the insurance company is set up, and every insurance company uses different systems – and so you can imagine that if an average worker’s comp doctor is dealing with say 15 insurance companies across the total practice, each insurance company might have a different vendor for scheduling an MRI or ordering durable medical equipment, or scheduling physical therapy, or only certain physical therapy offices are signed up for the network.
And the networks are created, in my opinion, to save and contain costs, which has to be done. But the other is to make sure you have willing participants in the network who will see a work comp case. And even when you pull up a list of people who are “in the network” a doctor’s office can spend a lot of time calling this list that’s published on the insurance website, like here are orthopedists in this zip code. And it’s really up to the doctor’s office to start making calls and ask if they will accept their patient.
Many times they will pick up the phone and hear that they haven’t taken work comp in years. Well why are you still on the list? And so this is the kind of issue that the PTP office runs into and this is the kind of wasted resources that happen because you have to hire someone to help the patient, to call and figure out the appointment, to fax it (the fax always gets lost), you fax it again, maybe the third fax they find. So there is a lot of wheel spinning that goes around.
And people wonder why does it take me six weeks to get my first physical therapy appointment? Well this is why, because there is so much bureaucracy behind the scenes. And so much confusion and poorly updated networks that when you’re really in the trenches helping people find care, it’s very difficult. And sometimes there is no one in the network at all. We will talk about that a little more.
But this is really the biggest miss that people understand about work comp is that these doctors are doing very heavy lifting when they’re bringing a new case into service and now you’re dealing with a new network or a new insurance. Or the insurance adjuster just changed, and we will talk about that too. But there is a lot of confusion, even for practices that have been around for a while as to how to help people navigate the system.
Cory: I think you’ve probably listed 10 different things that are involved with working with the network and I was trying to extrapolate that in my mind and basically for everything you said, the only way I could rationalize it is just to hire somebody new for the practice. The workload just seems so massive and then you multiply it by the number of networks you work with and everything, and then you compound that with the number of patients you have and it does seem like madness that can be controlled with correct staff and the correct PTP at the head of it.
Dr. John Alchemy: Yeah, but even with that it’s overwhelming. Even if you have great people and your staff isn’t turning over, and the insurance company staff isn’t turning over, you have to remember someone on your side could leave, or someone on the insurance side could leave, and rarely do you get notified if there’s a change on the insurance side unless you call them up and they say Mr. Smith is no longer here. Or Karen is covering for Mr. Smith but she’s on vacation. We don’t know who is covering for her, we will have to check with the claims manager about that.
Cory: She will be back in six weeks. Then she can tell you what Mr. Smith thinks. So, madness, absolute madness. And so now we’re getting to the point of finding a primary treating physician in the network. How does that work, John?
Dr. John Alchemy: Well if you think of this, that you’re on the Monopoly board, and you’re at the start, the first thing you have to do is find a PTP to help you go around the board. That is a big challenge for a lot of people and employers as well. They’re like, I pay a lot of money every month to have workers comp insurance, if I have an injured worker, I expect some service and I expect something for my money that I’m paying for.
So they call up the insurance company: I have an injured worker, I’m filling out my paperwork, they need to be seen. And the insurance company is supposed to have a network of PTPs that are willing to see them but the doctors are not always available, maybe they’re in a geographic desert where there is no work comp provider available. And you’re basically out of luck or you’re looking at driving 80-100 miles one way to find a doctor, to get seen. Or maybe you were just in the emergency room, your arm is in a cast, you’re taking norco, you’re running out of medication, you can’t go back to work, no one has written you a follow up work note, and you and the employer are basically just stranded.
So finding that PTP is a big deal and finding a PTP that’s a good fit for the patient is an even bigger deal. Because obviously patients and doctors don’t always get along, or see eye to eye, or have different opinions about how the care should be seen, or access to the doctor’s office if they have a question or need something. And you get stuck with the randomly assigned PTP for at least 30 days. And then you can change or you can get represented but again going into it patients and employers have no idea how this works unless they’ve had injuries before.
Cory: Absolutely. We were probably a little ahead on the tele-medicine thing, at least I will say probably, but we were ahead of that and basically the main reason we were such loud proponents of it from the get-go is the fact that opens up the opportunities for many to find work comp physicians in areas where there are, as you mentioned, no work comp physicians and you’d have to drive 50-100 miles to see one.
So finding a PTP in the network is easier now than ever but it’s still not easy because there is still some contention over workers comp and people still don’t know about it in general. So it’s easier now than ever but it’s still not easy.
Dr. John Alchemy: Yeah and I think the work comp system is kind of coming around and we’ve moved everything forward 5 years with tele-medicine in my opinion. But you know when you think about it, the insurance companies are willing to reimburse you for your mileage if you can find the form and if you can send it in you can get money back. And if you’re an injured worker, particularly if you’re not working, suddenly you don’t have any income. And 100 miles worth of gas is a really big deal. And if you’re asked to see the doctor every 45 days, that’s a big deal. You can’t pay your rent, that’s a big deal.
So there’s a lot of pressure on the injured worker suddenly and unexpectedly when they file a claim and if they can’t do tele-medicine, eventually they will just drop their claim or not get care or maybe go on to have unnecessary permanent impairment because they didn’t get the care in a timely fashion. It’s really sad when that happens and I’m really hoping that the industry comes around and realize that tele-medicine is an efficient way that really helps the core customers in work comp: the employer and the injured worker. Because that’s really what the whole system is here for.
Cory: Workers compensation is kind of one of those few things that are available to all people who are W2 employed and everything like that. There aren’t many things granted as rights to us that aren’t privatized like insurance so it’s awful to think that people aren’t getting help when it’s available to them.
Dr. John Alchemy: It is. So it makes it difficult on top of it, like I said a lot of times they have no idea how it works, they can’t get a call back, it’s just incredibly frustrating. And you know you’re not even going to get into the system or get care until you get a PTP. And the emergency room is not a primary treating clinic although sometimes you have to use it that way.
Cory: So, John, I have in my notes here something that I’m very curious about. And this is a prompt for a question that you gave to me. It’s not so much a question as it is a nice little phrase that says “Welcome to the game of musical chairs for adjusters.” And I would love to hear more about that.
Dr. John Alchemy: I’m just going to be speaking from my experience, but I’ve been doing work comp now for 25 years almost. There are adjusters that go the distance in their jobs and there are adjusters that just can’t take it for whatever reason. It is, by all means, a stressful job.
You have a lot of unhappy people calling you constantly, they’re all wanting something, and you’re expected to respond to them with some level of customer service and help. And so they’ve got employers calling in complaining to them that their employee can’t get seen or the employee is calling in because they’re hurt and can’t get seen, nothing’s getting done. Then you get the doctor calling in asking why they aren’t responding, this was approved yet the patient went in and was told they don’t have authorization. And then you throw the fourth party in there which is an attorney calling them to threaten litigation. You can understand why it’s maybe not your first choice as a vocation, to be a work comp adjuster.
As a result, and again these are my opinions, but many of these insurance adjusters do not last or they bounce between different companies. And I’ve seen that too.
Cory: Yeah, there’s a degree of burnout in that profession.
Dr. John Alchemy: Yeah, maybe more money and less stress, and then they get there and maybe it’s not what they were told. But this is a real challenge. People wonder why it takes 5 years to close a work comp case in California. Why does it take 27 visits for me to close my claim on a simple low back strain? And this is really at the core of it, is this incredible slowing down of time to have things happen.
I mean if you and I were having a remodel done on our kitchen and it would normally done in 3 months if there weren’t supply chain issues, if work comp were remodeling their kitchen we’d be looking at 3-4 years. Maybe one day out of two weeks the crew would show up and remove the counter and then another month and a half later someone would come and take the plate covers off the switches. I mean it’s glacial, the speed at which the system moves. And it’s totally amazing to me that anything can get done.
Cory: You might as well hire the city of Philadelphia to come and fix the kitchen.
Dr. John Alchemy: Yeah, you would know about that! But here in California it’s really frustrating for lot of people and I think insurance adjusters are equally frustrated with the system that they are placed in. They have limited control over it and it’s these networks and all the bureaucracy. What people don’t understand is work comp is the perfect storm of bureaucracy because it has this overlap of employment laws, employers, people that don’t really know medicine that are controlling medical procedures and medical care and then hiring all these people to act in proxy on their best interests and it’s so many cooks in the kitchen. Everyone is tripping over each other trying to get basic stuff done.
Unfortunately I think it’s getting a little worse and it’s not getting better. That’s my take on it. We will talk about that more, too.
Cory: Yeah, absolutely. As I’ve honed in on the idea of the system or rather zoomed out to the idea of the system multiple times, what you’ve said about insurance adjusters not wanting to do this either. So you look at this whole thing where everybody is sort of dissatisfied with something. Everything is lame and slow moving. I was just remembering – and this is sort of anecdotal – but I was telling someone about a concert that I had been to where it was a bunch of musicians playing together and they all knew each other. But one of the musicians that played preformed songs on 3 separate occasions at the show and by the third time you could kind of tell everyone on the stage and in the crowd was like, we could have just left this at 2. And you have to wonder whose idea this was anyway.
And it’s kind of awkward to stop a song right in the middle but we do have a system which is something that technically never stops. But there is a point in which something must be changed. So hopefully what we’re doing with tele-medicine in workers comp will help it change course. And stop it from steering into an iceberg like the Titanic or something.
Before we move to the last question, this is part one of two series as we mentioned in the introduction and so we’re coming around to our last question and we’ve discussed what a PTP is, what their workload is, and how this system is structured around them with medical networks. We discussed how to find a PTP in the network and why it’s difficult, and how the scheduling and all of the stakeholders that can get involved is really a game of musical chairs for adjusters. Now, we’re about halfway into this and you can already see quite well that the job is very difficult and we’re not even halfway through talking about the role of a PTP in workers compensation but as we kind of get ready to break this into two parts, we finally have to talk about the dark underworld of third party vendor scheduling.
Dr. John Alchemy: Well I think our listeners are going to ask two questions: Why is it a dark underworld? Who are the third party vendors?
And these third party vendors were invented about 5-6 years ago. And the idea was to remove some of the work for the insurance company and remove some of the work for the PTP and make it more efficient. And have this third party vendors know who all of the network vendors are and then you just tell the injured worker, someone is going to call you and they’re just going to take it from there.
Which sounds really good. I’m sure when they were coming up with these third party vendors that I’m sure it sold really well an it sounded great. Let’s get these injured workers back to treatment, we’re just dedicated to the logistics of calling the injured worker, getting them on the schedule. It’s going to be all sunshine and light.
Let me back up a little bit. Before the third party vendors came along, the doctor’s office would get authorization from the adjuster and get the network list and the doctors office would call a physical therapy office for a patient and set it up. It was a direct contact from the PTP’s office to the secondary treating clinic.
So then they bring in these third party vendors and that is taken away from the PTP clinic, and I think a lot of doctors thought it was great to have less work for their staff. Well, think again. Because the experience, and again I’m just talking about my experience and those I’ve talked to in the business, but the patient gets a mysterious call sometimes at 4 or 5 am from Florida. They don’t know what this call is, it doesn’t say who it is, sometimes a message is left or sometimes it isn’t. When they do leave a message they say hey it’s this third party vendor calling to schedule your MRI. And give us a call back.
Then you give them a call back and are put on permanent hold. I’ve had some patients on hold for 2 hours and then are just hung up on after 2 hours.
Cory: I’ve had that happen too. And let me say that the notion of a mysterious call from Florida is somehow terrifying to me!
Dr. John Alchemy: I mean if you’re in California…
Cory: Yeah, that’s true. I don’t think I even get scam calls from Florida. Respect to all our Florida listeners even though we’re talking about California things.
I guess using the term “third party” in that context when there are 5th, 6th, 7th parties in a work comp claim, even though they’re more lateral, makes me go, oh no. Who else wants skin in this game? But I can see where the enthusiasm comes from and where it drops off as well.
Dr. John Alchemy: Yeah so think about this. You get a call from a patient and they say they were on a call for two hours and got dropped and ask what happened. And now your back office has to call this third party vendor to find out what happened and guess what? They might be on hold for 2 hours and they might get dropped. And then you have to call the adjuster and say your third party isn’t doing what they need to do. Fix it. And they say, that adjuster was gone last week.
But you can see that this thing ultimately causes more problems than it solves. The problem is they have these centralized call centers, again in my experience, usually out East, and they’re trying to coordinate care for offices and they don’t know where they are located, they don’t know who is on the network. Sometimes they go as far to just put you on hold while they call over to the MRI office to make you an appointment. And that doesn’t go very well. You get dropped, the MRI office doesn’t pick up and they say they have to try again tomorrow. I mean the list just goes on and on.
Dr. John Alchemy: And I’ve had a patient that literally lived up by the Oregon border and they were told the nearest MRI center that the third party vendor could get them into was in Fresno. Like a 6 hour drive one way. And that’s just a non-starter. So then the PTP’s office has to call back to get an out of network authorization. So now we’re just doing it on our own but we’ve burned 3 hours of office time.
Cory: Exactly. And that’s 3 hours of office time for everybody in the office. That’s the cost of the employees working.
Dr. John Alchemy: Exactly. So again, just an amazing challenge, and the third party vendor was maybe something that was well intended once upon a time, and maybe it actually worked. But I think you could ask a lot of doctors, even the network facilities trying to work with the third party vendors and the patients and they would say this is just another obstacle to care. And it’s really, really frustrating when someone can’t wait because you’re concerned they have a severe meniscus tear and it’s going on 5 weeks. And they still can’t get their MRI and they can’t get anything off the ground. It’s that bad.
Cory: It is a very convoluted system and it’s definitely does not benefit from private additional entities, in my opinion.
Dr. John Alchemy: Yes, I think that’s very well said, Cory.
Cory: So next month we will be following up with part two of this series in which, as a quote that I’ve heard attributed to many people when you’re going through Hell, keep going. And we are currently in the dark underworld. And we will be emerging into the light of understanding in the next podcast. But that being said I don’t think we left this on a dark note by any means, I think we left it on an informative one.
So John, how should we recap the first half of this series today?
Dr. John Alchemy: Okay well first of all let’s remember this is like the rubber hitting the road podcast, this is like how the sausage really gets made in the PTP clinic. And a lot of people don’t want to know but we’re going to give you a little bit of the recipe here.
So just to recap what we talked about, what is the PTP in the real world and what are they expected to do? What kinds of tools and systems are they provided with to help the injured worker and the employer get this injury moving forward? Finding a doctor as a primary treating in the network, the access of the insurance adjusters and the turnover that’s challenging with them in their position and their perspective and what they’re expected to do. And lastly getting people scheduled for services and treatments using third party vendors. So that’s the recap, that’s what we’ve covered here today.
Cory: And we hope that you learned about some of the difficulties faced by PTPs. And if you’re an aspiring PTP I hope that we did not discourage you because as John has said in the past it is very rewarding. And if you are a PTP I hope you found it cathartic to listen to.
We will be back again next month. Thank you again for coming on the Podcast, John.
Dr. John Alchemy: Yep! We will back and do part 2 and we hope everyone joins us.
Cory: Thanks for listening. For more information about PTPs, workers compensation, visit our blog at blog.rate-fast.com and give RateFast Express a spin at rate-fast.com.