W.C. No. 4-462-794Industrial Claim Appeals Office.
January 23, 2003
FINAL ORDER
The respondents seek review of an order of Administrative Law Judge Stuber (ALJ) which determined that Dr. Rook is an authorized physician and ordered the respondents to pay for treatments he provided after November 30, 2001. We affirm.
The claimant sustained a compensable back injury in April 2000. Dr. Gibb became an authorized treating physician for the claimant’s injuries.
The ALJ’s findings concerning the authorization issue may be summarized as follows. Dr. Gibb made an unrestricted referral to Dr. Crute, a neurosurgeon. Dr. Crute examined the claimant in September 2000, but found no surgical problem. Instead, Dr. Crute referred the claimant for physical therapy which was performed in November and December 2000. Dr. Crute last saw the claimant in July 2001.
Dr. Crute practiced with and supervised Physician’s Assistant Parsons (PA Parsons). On October 22, 2001, PA Parsons spoke with the claimant and the claimant requested a referral to a pain specialist. The ALJ found that PA Parsons directed the claimant to Dr. Rook, who performed an evaluation on November 30, 2001, and made treatment recommendations. On December 20, 2001, PA Parsons wrote a referral to Dr. Rook on a prescription pad bearing Dr. Crute’s name.
The ALJ found that Dr. Gibb referred the claimant to Dr. Crute without limitation; therefore, the ALJ concluded Dr. Crute became an authorized treating physician. The ALJ further found that Dr. Crute, “acting through PA Parsons,” exercised independent medical judgment in referring the claimant to Dr. Rook. Therefore, Dr. Rook became an authorized provider, and the ALJ ordered the respondents to pay for treatment which he provided after November 30.
I.
On review, the respondents first contend the evidence does not support the finding that Dr. Gibb referred the claimant to Dr. Crute without limitation. Rather, the respondents argue that Dr. Crute was restricted to performing a neurosurgical consultation, and she was not authorized to refer the claimant for additional treatment. We are not persuaded.
When an authorized physician refers the claimant to another physician in the “normal progression of authorized treatment,” the physician to whom the claimant is referred becomes authorized to treat the claimant Greager v. Industrial Commission, 701 P.2d 168 (Colo.App. 1985). However, as the respondents correctly state, we have held that referrals may be limited to specific purposes or treatments, and in such cases the physician to whom the claimant is referred does not become authorized to make referrals for additional treatment. Eg. Smith v. Denver Public Schools, W.C. No. 3-861-421 (March 6, 1992). The questions of whether a referral was made as part of the normal progression of authorized treatment, and the scope of the referral, are questions of fact for determination by the ALJ. City of Durango v. Dunagan, 939 P.2d 496
(Colo.App. 2001); Smith v. Denver Public Schools, supra.
Because these issues are factual in nature, we must uphold the ALJ’s determination if supported by substantial evidence in the record. Section 8-43-301(8), C.R.S. 2002. This standard of review requires us to defer to the ALJ’s credibility determinations, resolution of conflicts in the evidence, and plausible inferences drawn from the record. Wal-Mart Stores, Inc. v. Industrial Claims Office, 989 P.2d 251 (Colo.App. 2001).
The respondents’ argument notwithstanding, the record contains substantial evidence to support the ALJ’s finding that Dr. Gibb made a general referral to Dr. Crute, and no limitation was placed on Dr. Crute’s power to make additional referrals for treatment. First, as the ALJ explicitly found, the record does not contain any written referral from Dr. Gibb to Dr. Crute. Consequently, there is no written evidence that Dr. Gibb placed any limitation on Dr. Crute’s authority to treat the claimant and make referrals which Dr. Crute deemed necessary. Further, the mere fact that Dr. Crute’s specialty is neurosurgery, and that Dr. Gibb referred the claimant for a neurosurgical evaluation, does not mean that Dr. Crute’s authority to perform treatment or make referrals was limited solely to surgery. Indeed, as the ALJ found, there is evidence that Dr. Crute referred the claimant for physical therapy in November and December 2000. (Crute Depo. pp. 23-24). Although the respondents assert the claimant was receiving physical therapy based on a referral from other sources and Dr. Crute merely concurred in this recommendation, they do not identify any evidence in the record to support that assertion. However, even if such evidence existed, the ALJ implicitly resolved the conflict against the respondents and found that Dr. Crute referred the claimant for the therapy.
Finally, the fact that Dr. Crute admitted limitations in her expertise hardly means that she was not empowered to refer the claimant to physicians or providers capable of rendering needed treatment. Indeed, one may suppose that an important skill of the specialized physician is the ability to recognize medical problems outside the physician’s expertise and make appropriate referrals for treatment. Finally, there is no legal requirement that in order to make a referral an otherwise authorized physician must be the “primary” treating physician.
II.
The claimant next contends the ALJ erred in finding that the referral to Dr. Rook by PA Parsons is the equivalent of a referral by Dr. Crute. We disagree with this assertion.
As noted, the issue is whether the referral occurred in the “natural progression of authorized treatment.” Nothing in that phrase necessarily limits the power of referral to physicians. To the contrary the proper scope of the inquiry is the natural progression of treatment in the medical profession, and this is an evidentiary issue for the ALJ. Of course, a referral must be the product of independent medical judgment by the referring provider. City of Durango v. Dunagan, supra.
Here, Dr. Crute testified that she supervises PA Parsons, and that PA Parsons has the legal authority to prescribe treatment including medications. Further, Dr. Crute testified that PA Parsons’ referrals are done under her auspices and are essentially referrals of Dr. Crute herself. (Crute Depo. pp. 13, 27). This testimony is consistent with case law discussing the legal status of a licensed physician’s assistant. Sims v. Industrial Claim Appeals Office, 797 P.2d 777
(Colo.App. 1990). Thus, there is ample evidence that PA Parsons had the legal authority to refer the claimant to Dr. Rook, and to support the ALJ’s finding that the referral was legally equivalent to a referral by Dr. Crute.
The respondents also assert that because Dr. Crute agreed with a report of Dr. Campbell which recommended pain treatment by Dr. Bissell, Dr. Crute could not have exercised “independent medical judgment” when referring the claimant to Dr. Rook. However, the mere fact that Dr. Crute agreed that Dr. Bissell was an appropriate person to provide treatment does not preclude a subsequent determination that another physician is also qualified to provide the treatment. This is particularly true where, as here, the respondents did not provide treatment with Dr. Bissell before Dr. Rook became authorized. Further, there was evidence that PA Parsons conducted a search for a suitable provider, and that Dr. Crute agreed Dr. Rook was qualified to provide the treatment. (Crute Depo. pp. 33-34). Substantial evidence supports an inference that PA Parsons, and hence Dr. Crute, exercised independent medical judgment in referring the claimant to Dr. Rook.
III.
The respondents next contend the claimant effected an impermissible “end run” around the statutory authorization procedures by procuring the referral to Dr. Rook through PA Parsons. Further, the respondents assert the claimant “dictated” her treatment in violation of § 8-43-503(3), C.R.S. 2002.
The mere fact that a claimant requests a referral for a particular type of treatment or to a particular provider does not mean that, if a referral is made, the referral necessarily falls outside the natural progression of treatment. Rather, the issue remains one of whether the referring physician exercised independent medical judgment in making the referral. City of Durango v, Dunagan, supra. Here, as we have held, there is evidence to support the inference that the referral to Dr. Rook was deemed necessary by PA Parsons, and that she conducted an investigation to determine who should provide the treatment. The record does not conclusively establish that Dr. Rook’s name was suggested to PA Parsons by the claimant or her attorney. Indeed, Dr. Crute surmised from the record that the insurance company may have suggested Dr. Rook. (Crute Depo. pp. 33-34). In any event, the ALJ plausibly inferred the selection of Dr. Rook was the product of independent judgment, not improper conduct by the claimant.
Neither is there any basis to find the claimant “dictated” treatment. As the ALJ found, the evidence indicates the claimant “requested” a referral to a pain specialist. The respondents point to no evidence that the claimant threatened PA Parsons or intimidated her into taking any action, including the referral to Dr. Rook. Consequently, the claimant did not “dictate” her treatment for purposes of § 8-43-503(3). Cf. Provo v. Industrial Claim Appeals Office, __ P.3d __ (Colo.App. No. 01CA1239, September 12, 2002) (respondents’ attorneys did not “dictate” treatment by recommending to client that it contest liability for chiropractic treatments).
The respondents’ remaining argument is merely a reiteration of the prior arguments, and it is rejected. Substantial evidence supports the order for the reasons stated above.
IT IS THEREFORE ORDERED that the ALJ’s order dated July 22, 2002, is affirmed.
INDUSTRIAL CLAIM APPEALS PANEL
___________________________________
David Cain
___________________________________
Kathy E. Dean
NOTICE
This Order is final unless an action to modify or vacate this Order iscommenced in the Colorado Court of Appeals, 2 East 14th Avenue, Denver,CO 80203, by filing a petition for review with the Court, within twenty(20) days after the date this Order is mailed, pursuant to §8-43-301(10) and § 8-43-307, C.R.S. 2002. The appealing party mustserve a copy of the petition upon all other parties, including theIndustrial Claim Appeals Office, which may be served by mail at 1515Arapahoe Street, Tower 3, Suite 350, Denver, CO 80202.
Copies of this decision were mailed _______January 23, 2003___ to the following parties:
Linda Phelps, 0515 E. Blarney Stone Rd., Howard, CO 81233
Heart of the Rockies Regional Medical Center, 550 Highway 50, P.O. Box 429, Salida, CO 81201-0429
Colorado Hospital Association Trust, c/o Support Services, P.O. Box 3513, Englewood, CO 80155-3513
Stephanie J. Stevenson, Esq., 815 N. Nevada, Colorado Springs, CO 80903 (For Claimant)
Gary L. Fleming, Esq., and Harvey D. Flewelling, Esq., 5353 W. Dartmouth Ave., #400, Denver, CO 80227 (For Respondents)
By: __________A. Hurtado__________