Injured workers filing workers compensation claims must get a physician progress report at each doctor’s visit. These reports inform the worker’s employer and insurer of diagnosis, treatments, and work capability.
Physician Progress Reports Impact Benefits
A treating physician’s opinion and diagnosis carry a lot of weight in a workers compensation case. At each doctor’s visit, an injured worker should request a copy of the physician progress report (PPR) that shows notes about the worker’s injury, diagnosis, treatments, physical limitations, improvements, and work status. A treating physician makes important decisions that directly impact workers compensation benefits.
Most doctors who treat workers compensation cases are on the insurer’s preferred provider list. They use standard DIR-approved physician progress report forms (form D-39 in Nevada) to note medical information and the status of injuries. It’s important for the patient to obtain a copy of the report and carefully read it after each doctor’s visit to make sure he/she is in agreement with the doctor’s diagnosis and return to work status. Each PPR shows whether the doctor has released the workers to return to full employment or indicated temporary work restrictions. The worker’s employer and the insurance company will receive a copy of each PPR form which is divided into three sections:
- Section 1 – States the nature of the injury, the severity of the injury, and the diagnosis. If a worker disagrees with this information, the doctor should be informed in case further examination is needed.
- Section 2 – Indicates when the doctor releases the worker from medical care. The doctor checks boxes that show the possibility of permanent disability. If boxes are checked “no” or “none”, the insurance adjuster may schedule a permanent partial disability evaluation, which is necessary to receive an injury settlement. Section 2 also contains a “Treatment Plan” indicating the doctor’s request for further medical treatments, physical therapy, and referral to a specialist.
- Section 3 – Indicates whether the doctor has taken the injured worker out of work completely (temporary total disability), or put him/her on temporary work restrictions. If temporary work restrictions are indicated, the worker must give a copy of the form to his/her employer and check on work availability with such restrictions. If work is available, the insurer will not continue to pay bi-weekly TTD benefits.
The Impact of the Treating Physician
Insurance companies that pay workers compensation benefits rely heavily on an injured worker’s treating physician for information. The treating physician makes important medical decisions that impact a worker’s claim and benefits.
Diagnosis and Treatment
To receive workers compensation benefits, a diagnosis of injuries by a licensed physician is required. The treating physician (primary physician) is responsible for providing or overseeing all necessary medical care and medications.
Referrals to Specialists
The treating physician is required to approve any referrals to specialists. Like most HMO medical plans, the treating physician acts as a primary physician for general care. If specialists such as physical therapists, orthopedists, ophthalmologists, oncologists or surgeons are needed, the treating physician will have to sign off on the request.
The treating physician decides if a worker needs time off from work for recovery, or if the worker can return to work with temporary job restrictions. This decision impacts benefits for temporary, partial, and permanent disability payments.
The treating physician determines a worker’s level of permanent disability. Once maximum medical improvement is reached through treatments, the physician evaluates the degree of permanent disability. The physician’s conclusion is used to calculate the worker’s permanent disability benefits.
Choosing a Treating Physician
Workers Comp laws on choosing a treating physician vary from state to state. In Nevada, it’s a state requirement that an injured worker must choose a treating physician from an authorized medical provider on the list of Treating Physicians and Chiropractors. However, the worker is allowed to change treating physicians within 90 days of the date of injury, if he/she is not satisfied with treatments or services. If a physician change request is made after 90 days, the insurance company must approve the change. Insurers may list physicians within preferred provider organizations, managed care organizations, healthcare maintenance organizations, or the insurer’s managed care unit.
Treating physicians who handle workers compensation cases are sometimes pressured by workers comp case managers and insurance adjusters to return an injured worker to his/her job as quickly as possible. This often means sending a worker back to the job with work restrictions, rather than time off from work for recovery. If this happens, the worker must either return to work based on the indicated job restrictions or take time off without pay. If the worker does not feel physically able to return to work under those conditions, he/she can request a physician change to get another opinion, as long as it’s within 90 days of the injury date.