Managing the Treating Doctor Relationship
MODULE 1: LESSON 6
In Texas workers’ compensation, the treating doctor serves as the medical anchor of the claim. For employers and adjusters, how this relationship is managed has a direct impact on:
Medical outcomes
Return-to-work success
Benefit accuracy
Dispute exposure
A poorly managed treating-doctor process creates confusion and risk. A well-managed process creates clarity, consistency, and defensible decisions.
Why the Treating Doctor Matters to the Claim
The treating doctor is more than a health care provider. From a claims-handling perspective, the treating doctor:
Establishes the treatment plan
Determines work status and functional restrictions
Completes the DWC Form-073 Work Status Report
Provides medical opinions relied on by insurance carriers and the Texas Division of Workers’ Compensation
These medical opinions influence benefit eligibility and return-to-work decisions. They also shape dispute outcomes throughout the life of the claim.
Key Takeaway
The quality and consistency of the treating doctor’s communication often determine whether a claim progresses smoothly or becomes disputed.
Health Care Networks: Employer and Adjuster Responsibilities
Many Texas employers participate in a workers’ compensation health care network.
When a network applies:
The treating doctor must be selected from the network’s approved provider list
Referrals and treatment must comply with network rules
Treatment obtained outside the network, especially early in the claim, can result in:
Medical bills that are not reimbursable
Delays in care
Disputes over compensability or the extent of injury
These issues can arise even when the injury itself is legitimate.
Non-Network Claims: Managing Provider Selection
When no health care network applies, the injured employee may choose any DWC-approved treating doctor.
What Matters
From a claims perspective, effective treating doctors typically:
Understand Texas workers’ compensation requirements
Communicate work restrictions clearly and specifically
Complete DWC Form-073 accurately and on time
Working with providers unfamiliar with Texas workers’ compensation often increases administrative friction and risk of a dispute.
Changing Treating Doctors: Compliance Is Critical
Texas allows a change of treating doctor, but only through a defined process. To change treating doctors:
The employee must file DWC Form-053
A reason for the change must be stated
Approval must be obtained from the Division of Workers’ Compensation before the change occurs
Caution
Unauthorized doctor changes frequently result in:
Denied or unpaid medical bills
Conflicting work status reports
Disputes involving maximum medical improvement or impairment ratings
Adjusters should monitor provider changes closely and confirm authorization status before relying on related bills or reports.
Managing the DWC Form-073: A Shared Responsibility
For employers and adjusters, the DWC Form-073 drives several critical claim decisions, including:
Issuing temporary income benefits
Planning for return-to-work
Tendering bona fide offers of employment
Recommendation
Review each DWC Form-073 promptly upon receipt
Confirm that restrictions are specific, clear, and job-related
Address inconsistencies or vague language directly with the provider
Real World Example
Two similar injuries. Two very different outcomes.
In Claim A, the treating doctor provides timely DWC Form-073 reports with clear restrictions. The employer accommodates the employee’s restrictions. The adjuster adjusts benefits as necessary. The employee returns to work safely and predictably.
In Claim B, the treating doctor delays reports and provides vague restrictions. The employer guesses at job duties. The employee struggles to perform the work assigned. The adjuster disputes wage benefits. The claim escalates into formal dispute resolution.
Same injury.
Very different results.
The Goal
For employers and adjusters, the objective is not to control medical treatment. The objective is clarity, compliance, and effective communication.
Key Takeaway
When the treating-doctor process is managed effectively:
• Employees recover more predictably
• Employers provide return to work options more appropriately
• Adjusters make accurate and defensible decisions
For employers and adjusters, managing the treating doctor relationship is not about control. It is about creating the conditions for clarity, trust, and better outcomes for everyone involved.
Knowledge Check Questions
1. Why does the treating doctor have such a significant impact on a workers’ compensation claim?
a. The doctor determines who is at fault
b. The doctor directs treatment, sets work restrictions, and provides key medical opinions
c. The doctor negotiates settlements
d. The doctor approves insurance coverage
2. What problem can occur if an injured employee treats outside of an approved network when one applies?
a. The claim is automatically denied
b. The employee loses all benefits permanently
c. Billing issues, delays, and compliance problems may arise
d. The employer takes over medical decisions
3. Why can changing treating doctors without proper approval create complications?
a. It increases medical costs only
b. It leads to multiple opinions, conflicting restrictions, and disputes
c. It automatically qualifies the claim for litigation
d. It speeds up the claim process
4. Why is the DWC Form 073 so important in a claim?
a. It determines legal liability
b. It documents the initial injury report
c. It drives work status, income benefits, and return-to-work decisions
d. It replaces medical records
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b
c
b
c
