The role of the designated medical provider

In workers’ compensation terms, the primary care provider (PCP), also referred to as the designated medical provider, is the key to effective and efficient medical treatment for injured workers. The PCP’s role is to provide the right care at the right time so the worker receives appropriate, timely and cost effective care. With their occupational medicine focus, these PCP’s are able to prevent overutilization while delivering compassionate care.

Who is the Primary Care Provider?

At the onset of any injury or illness, the Division of Workers’ Compensation (DOWC) requires the employer to provide a list of designated healthcare providers from which the injured worker can select. The physician whom the employee sees on the first visit becomes the authorized treating provider.

This provider remains the PCP unless:

  • The insurer and patient agree to change providers;
  • The worker decides to use their option for one unchallenged change of treating physician within 90 days of the injury; or
  • A judge orders a change in provider.

PCP Case management functions:

  • Assessing causality;
  • Determining physical work restrictions and managing disability;
  • Educating the injured worker and communicating with all parties;
  • Initiating and managing referrals for specialty care;
  • Determining Maximum Medical Improvement (MMI) and permanent impairment; and
  • Discharging the injured worker from care.

Referrals

The PCP arranges and authorizes any necessary referrals throughout the injured worker’s recovery. Although the worker may see specialists during the course of treatment, the PCP oversees and controls care coordination.

Claim Initiation/Outset

The provider’s initial role is to:

  • Determine causality by assessing the medical probability by satisfying all of these requirements:
    • An on-the-job event or occupational exposure took place;
    • The injured worker has been properly diagnosed with an injury or disease;
    • The event or exposure was sufficient to have caused the injury or disease; and
    • It is medically probably that the event or exposure caused the injury or disease.
  • If the condition is work related, continue with a treatment plan based on DOWC Medical Treatment Guidelines
  • Determine physical activity and work restrictions
  • Discuss the diagnosis, treatment plan and return-to-work plans with the injured worker

Ongoing treatment

The provider’s role in follow-up visits is to continue treatment as needed.

  • Determine physical activity and work restrictions;
  • Provide regular follow-up care to assure progression;
  • Initiate and manage referrals for specialty care; and
  • Communicate any work status changes to Pinnacol and the employer.

Claim Closure

  • Determine MMI — the point at which no further treatment is reasonably expected to improve the worker’s condition
  • Assign a permanent impairment rating of disability (must be completed by a Level II physician in accordance with DOWC rules)
  • Discharge the injured worker from care or provide maintenance care after MMI

Nurse practitioners or physician assistants

A nurse practitioner or physician assistant can see the worker and by the third visit, a physician must see the patient.

Following emergency or urgent care

If the worker is seen in the ER or urgent care, the next visit must be with the designated medical provider. The worker will not return to the emergency room for follow-up care.

References

Authorized treating providers (ATP): Rule 8

Utilization — Standard Terminology: Rule 16(2)

Questions?

Please contact Provider Relations at (303) 361-4945 or provider_management@pinnacol.com.