PTPs, SPQMEs, and You: Treatment and Evaluation of Your Work-Related Injury or Illness
Your employer, through its insurer, is responsible for paying for necessary medical treatment and rehabilitation for the illness or injury you suffered while working. That’s the good news. The bad news is that payment comes with strings attached, including the fact you may have little control over who provides your care.
If you’re injured at work or suffer an illness because of your job, you may qualify for workers’ compensation benefits. Call the experienced team of Inland Empire workers’ comp attorneys at Castillo & Associates at 800-497-9774 today if you have questions or want legal representation to help you through the process.
What is a PTP?
Your PTP is your primary treating physician. In addition to providing care, your PTP renders opinions on medical issues that may decide your ability to collect compensation. Their reports are presumed to be correct, but if either side disagrees with them, you may get an independent medical examination.
You may be able to choose this person if you made some decisions and took some action before you became injured or ill, including:
- You have health insurance covering injuries and illnesses that are unrelated to work injuries
- You gave your employer written notice before your injury or illness of your preference for a physician or medical practice (a “predesignation”), and
- They agreed in advance to treat you for work-related injuries or illnesses
If your employer or its insurer contracts with a healthcare organization (HCO) to provide managed care for work-related injuries and illnesses, you can predesignate your preferred healthcare provider if you give your employer the proper form when you were hired and annually afterward.
If you didn’t take those steps, you’ll probably be required to see a physician employed by the workers’ compensation carrier’s or your employer’s designated medical provider network (MPN) or HCO. The exceptions are that you need emergency medical care or your employer failed to give you the required information or notices about the process.
If the employer or their insurer contracts with an HCO, you’ll be required to see a physician in the HCO immediately after your injury. Even without a designated MPN or HCO, the workers’ compensation claims administrator can usually choose your treating physician for the first 30 days after your injury.
Changing Your PTP
If you’re not comfortable with your PTP, you can seek another within the MPN or HCO or try to go outside it. If you’re uncomfortable with your PTP or strongly disagree with their decisions concerning your ability to work, how to see a new physician depends on whether or not there’s an MPN or HCO involved. The process involves:
- No MPN or HCO: You can switch once 30 days after reporting your illness or injury. Unless you have designated who will treat your work-related health problem before your injury, the claims administrator can generally choose the new doctor. After the 30-day period expires, you can select your new PTP within a reasonable distance from your home.
- Your employer has an MPN: You can ask to switch, but the initial changes must be within the MPN. You can seek an independent medical review if you disagree with the third doctor’s opinion. Depending on the outcome, you may be able to see someone outside the MPN.
- Your employer has an HCO: If your physician is part of an HCO, you can switch at least once. After 180 days, you can use another PTP if your employer provides healthcare benefits and 90 days if they do not. The new treating physician must be within a reasonable distance from your home.
The US healthcare system is highly complex and the most expensive in the world. California’s workers’ compensation adds another layer of complexity if you have a work-related illness or injury. When one of our workers’ comp attorneys represents you, they will help you navigate this system for the best possible care.
What is an SPQME?
A State Panel Qualified Medical Evaluator is a medical professional certified by the California Division of Workers’ Compensation Medical Unit. Their main role is to provide a neutral, impartial evaluation of your medical condition and disability status.
Your PTP, given who pays them, may be biased in favor of your employer or insurer. An SPQME’s assessments can cover the extent of your illness or injury, may give you a disability rating, and may impact your benefits.
As part of the claims process, a medical professional whom we, your employer, or their carrier retain may examine you for their opinion.
After the SPQME reviews your medical records, examines you, considers any additional testing they may order, and writes a report with its conclusions and findings, it is given to the workers’ compensation administrative judge overseeing your case. The judge will consider the report and other evidence to determine if you qualify for benefits and, if so, your medical treatment and temporary and permanent disability payments.
Speak With an Experienced Workers’ Compensation Lawyer in Inland Empire
If you’re considering filing a workers’ compensation claim or have started the process and your claim is denied, seek legal counsel as soon as possible.
With more than thirty years of experience, Castillo & Associates Inland Empire workers’ compensation lawyers have the skills to handle the complex medical, legal, and insurance challenges associated with workers’ compensation claims. If you are injured or become ill at work, contact our firm today to learn more about your legal options and how we can help.
Attorney Domingo Castillo handles workers’ compensation, personal injury, family law & immigration throughout Southern California from our 5 offices: Indio, Pomona, Riverside, San Diego & Cathedral City. We help clients file injury claims, obtain residency & citizenship, and we assist families through divorce, child custody and all family law matters.
