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The issues workers and employers face are often the same or similar to those of their treatment providers and doctor. The obstacles outlined and strategies suggested may help you better understand what may be happening to stakeholders in the workers compensation system at a given point in time. Ideas are offered for supporting the various stakeholders assisting injured workers recover and get back to work.
What is happening
It is now more than 12 months since your patient's injury claim was lodged and they are still in the workers compensation system. A number of unexpected challenges are likely to have been experienced as well as unexpected setbacks. Inevitably, secondary or tertiary health issues are likely to have followed including , social, psychological, financial and employment difficulties.
In the following sections the most commonly experienced challenges are outlined by workers who have been in “the system” for more than a year are discussed. Suggestions are made on ways injured workers can be supported to deal with these challenges including where to find the right types of of advice or support for particular circumstances.
The injury itself -
Workers who are in the system for 12 months or more are likely to have one or more of the following:
What the injured workers need to consider -
When surgery didn't do what it was suppose to do - i.e unexpected side effects and complications from the surgery.
What the injured worker and treatment providers need to consider-
Side effects and complications from treatments such as medications - e.g. physical dependence, inadequate pain control , liver or kidney problems
What the injured worker and treatment providers need to consider-
Whether the NTD who is aware of these issues and will explore alternative treatment options e.g. referrals to therapists who can use alternate strategies that minimise medication problems.
Secondary Physical injuries - e.g: A significant injury to a left knee or leg may result in changes of posture - leading to back problems - it may also result in the injured person favouring the other leg and overuse problems occurring in that knee. This occurs frequently with leg, knee, arm, hand and shoulder injuries. - Resulting insurer liability and subsequent treatment problems can be a significant challenge.
What the injured worker and treatment providers need to consider-
Secondary Psychological Injuries- Anyone who is caught up in the workers compensation system for more than 3 months, irrespective of the type and extent of injury is likely to have faced challenges they may have never had to deal with before. After 12 months it is likely that:
All these challenges inevitably lead to increased levels of stress, even in people who manage the demands of everyday life very effectively. Many of challenges outlined cannot be “solved” easily if at all. This can result in frustration, anxiety and anger that may flow on and result in depression, and anxiety, particularly when the person's life situation does not seem to be improving and there are numerous difficulties being faced on a day to day basis.. Secondary psychological injuries (put another way, psychological and social health problems) are almost inevitable after 12 months for most people if they do not have the right support and progress isn’t being made.
What the injured worker and treatment providers need to consider-
12 MONTHS AND BEYOND - A DIFFERENT APPROACH IS NEEDED TO INJURY MANAGEMENT
At 12 months there needs to be a fundamental shift in approach to injury management with most injuries and most workers. The emphasis needs to change from finding the best treatments to one where the focus moves to adjusting to living with permanent residual restrictions and pain. Psychological counselling / and or pain management counselling is often very helpful with this. (See Pain Management and Injury Adjustment Interventions and Pain Management and Injury Adjustment Interventions)
Twelve months after the worker's initial injury there are usually multiple stakeholders involved in a claim. Issues involved in both the claim and injury process are often complex and conflict is common. In the following sections the most common problems are overviewed and strategies suggested to minimise or resolve the issues.
Industrial and workplace issues can be a major barrier to an injured worker returning to full or near full capacity in their preinjury work place. In the information file 1-3 Months - What is happening / should be happening the following issues were mentioned as common workplace barriers:
Twelve Months down the track most employers will have accepted that the injury is work related (even if they have continuing suspicions that it is not) and will be aware of the their obligations to provide suitable duties. It is also likely that the employer will have had advice about their legal and injury management responsibilities at this stage and will be attempting to provide at least token levels of support. The vast majority, particularly if they are being provided with good information and support from an external rehabilitation provider and their insurer will be active participants in the return to work process.
After 12 months many small to medium size employers will be finding it costly to have had to make a workers compensation in terms of time, money, and unexpected considerations addressing staffing and business requirements. Employers are required to provide suitable duties for their workers. For a small employer - i.e. less than 20 staff their obligations can seem onerous. The personality of the manager and business owner, the circumstances of injury, their experiences with the worker since injury, and the general health of the business are all factors that can strongly influence the attitude of the an employer to the injured worker, to the treatment team and to injury management experience generally. Where there relationship and attitude with the injured worker is poor, additional barriers to a successful return to work outcome are likely. These include:
What the injured worker and treatment providers need to consider-
Problems with Diagnosis and Treatment
After 12 months from date of injury the vast majority of injuries will have healed completely. For those that haven’t it is likely that the pain and functional restrictions from the injury are unlikely to improve significantly, even with a different approach. There are exceptions of course such as head injuries - which may take up to 3 years, and some complex injuries where there were unexpected complications.
There are also situations where the management of the injury has been poor. Some of the circumstances include:
Treatment provider problems such as:
Insurer/ Agent Issues
It was mentioned in the initial information document that the insurers / agents are the managers, gate keep and bean counters of the NSW Workers Compensation system. It was also mentioned that the relationship injured workers, nominated treating doctors, treatment providers and rehabilitation providers have with the claims officer managing a particular injured workers claim can and does make an enormous difference to how quickly decisions are made, referrals and treatments approved and payments made. By 12 months this will havebecome increasingly apparent to all the stakeholders who are required to deal with an agent responsible for a particular claim.
Positive Agent Experiences
There are situations where 12 months down the track where:
The feedback from workers who have had positive experiences includes comments on supportiveness, reasonableness in decision making, paid on time, works in with the treatment team.
Negative Agent Experiences
In the first information doc "Time of injury to 1 month", it was mentioned that the majority of complaints made to WorkCover by injured workers and treatment provider relates to agent related problems. Unfortunately this remains so through the life of a claim and for various reasons.
The situations where problems develop with the agent is the opposite of "Good Experiences" and can be summarised as:
Some of the typical problems reported by injured workers after 12 months are outlined below:
Problem | Suggested strategies |
Wages not paid on time by agent
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Wages not paid by employer
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Wages do not appear correct
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Expenses for travel to medical appointments and or medication are not reimbursed by insurer or there are extensive delays
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Suggest the injured worker initially call the agent and their claims manager to ascertain whether the documentation has been received and ask when will it be processed.
If payment is not forth coming suggest they consider calling Workcover's help line.
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Insurer ignores a request for a procedure or support service - e.g. home help, treatment referral.
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Suggest the injured worker consider the following:
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Have a support a service or referral refused by the agent including your own
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Suggest the injured worker consider the following, and or undertake yourself:
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Agent refers for an Independent Medical Assessment and the opinion is significantly different concnering the plan of management for the injury than that of the NTD and other memebers of the worker's treatement team.
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Suggest the injured worker consider the following:
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A Work Capacity Assessment is carried out and the findings are inconsistent with the injured worker's injury experiences, feedback from their treatment team, and from their perceived real work capacities and work experiences
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At this point time there are no mechanisms in place to challenge work capacity decisions except on procedural grounds – I.e. not enough time allowed to attend assessment, assessment not submitted within time frames. The issues involved with the newly established Work capacity assessments (including the right to legal representation to contest assessment findings) are currently being worked out
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Time Frames for Approval
Slow responses to treatment and rehabilitation service requests, for specialist’s referrals and for investigative procedures are the area where most complaints are made to Workcover’s Claims Assistance Service. It is important for Injured Workers and treatment providers to know that not all services require agent approval providing there is a valid claim.
Below is a summary of relevant parts of the current WorkCover Act relating to services needing agent approval, what services don’t and what the avenues of appeal are when there is slow or non response from the agent.
WHAT WORKCOVER HAS TO SAY
“If the worker has paid for reasonably necessary medical treatment, the insurer is to reimburse the worker within 7 days after the worker requests payment. If the worker has paid for travelling expenses to receive medical treatment or to attend a medical appointment that the insurer has arranged, the insurer is to reimburse the worker within 7 days after the worker requests payment. “
If the insurer does not respond to a new claim or a request for a specific benefit under Part 3, Divisions 2, 3 and 5 of the 1987 Act within 21 days, the worker can seek assistance from Work Cover’s Claims Assistance Service (CAS) on 13 10 50 or their union. CAS will issue the worker with a CAS reference number upon initial contact and then contact the insurer to facilitate a response. CAS will send a letter to the worker within 7 days of the request advising either:
• The insurer’s response (i.e. the action the insurer has taken or will take); or
• That there is still no response.
Once the 7 days has elapsed, the worker may lodge a dispute with the Workers Compensation Commission (WCC) quoting the CAS reference number and attaching the CAS letter. For the purpose of relying on the CAS reference number or letter to commence proceedings in the WCC, the CAS inquiry must be made no earlier than 7 days before the time limit for determining the claim has expired. The worker or their representative may also need to refer to the WorkCover Work Capacity Guidelines regarding payment of weekly payments
Exemptions: The following treatments are exempt from the requirement for prior insurer approval. (Note: These exemptions only apply where provisional liability for medical expenses or liability for a claim has been accepted).
3.2.1 Nominated treating doctor
Any consultation with the nominated treating doctor in relation to the injury claimed except for consultations for mental health treatment items AA905 and AA910 in current Australian Medical Association List of Medical Services and Fees.
3.2.2 Specialist medical practitioner
The first consultation for the injury with a specialist medical practitioner, on referral by the worker’s nominated treating doctor.
3.2.3 Pharmacy
3.2.3.1 Pharmacy items prescribed by the nominated treating doctor or specialist medical practitioner for the injury in the first 3 weeks post injury, to a maximum of $500.
3.2.3.2 Pharmacy items excluded from the Pharmaceutical Benefits Schedule to a maximum amount of $100.
3.2.4 X-Ray
All plain x-rays performed on referral from the nominated treating doctoror specialist medical practitioner in relation to the injury claimed and provided within one week of injury.
3.2.5 Public hospital
Any services provided in public hospitals that are provided by or consequent upon presentation at the hospital’s emergency department for the injury claimed that is within one month of the date of injury.
3.2.6 Physiotherapy, Osteopathy or Chiropractic treatment
3.2.6.1 The initial consultation and up to a further seven treatment sessions provided by a registered practitioner where:
a) The injured worker has not previously received treatment for the injury claimed, or
b) The treatment resumes with the same practitioner within a three month period from the last treatment and less than eight treatment sessions were provided originally.
c) The treatment resumes with the same practitioner within a three month period under a previously approved planand deemed as the same episode of care.
3.2.6.2 The initial assessment for a new episode of care where a worker ceased treatment more than three months previously and returns for additional treatment for the same injury. The registered practitioner cannot utilise any remaining treatment sessions that may have been approved under the previous episode of care.
3.2.7 Psychology treatment or counselling
3.2.7.1 The initial consultation and up to a further five treatment or counselling sessions provided by a WorkCover approved practitioner where:
a) The injured worker has not previously received treatment/counselling for the injury claimed, or
b) The treatment/counselling resumes with the same practitioner within a three month period from the last treatment and less than six treatment sessions were provided originally.
c) The treatment/counselling resumes with the same practitioner within a three-month period under a previously approved plan and deemed as the same episode of care.
3.2.7.2 The initial assessment for a new episode of care where a worker ceased treatment/counselling more than three months previously and returns for additional treatment/counselling for the same injury. The registered practitioner cannot utilise any remaining treatment/counselling sessions that may have been approved under the previous episode of care.
3.2.7.3 The preconditions to be met before the exemption will apply are:
a) The psychologist must be WorkCover approved and
b) The injured worker’s nominated treating doctor or treating specialist medical practitioner who is a psychiatrist must make the referral for treatment.
3.2.8 Remedial Massage
3.2.8.1 No more than 5 sessions of remedial massage, where there has been no previous remedial massage therapy for the injury claimed.
3.2.8.2 The precondition to be met before the exemption applies is:
a) The remedial massage therapist must be WorkCover approved.
3.2.9 Hearing needs assessment
3.2.9.1 The initial hearing needs assessment only.
3.2.9.2 The preconditions to be met before the exemption will apply are:
a) The hearing service provider must be WorkCover Approved and
b) The injured worker’s nominated treating doctor is to have referred the worker to a treating specialist medical practitioner who is an ear, nose and throat physician to determine that the hearing loss is work-related and that there is binaural hearing loss of 6% or more. The ENT makes the referral for treatment.
Worker Issues, Social Issues and Financial Issues
It was mentioned in previous docs that as well as the factors outlined above return to work outcomes can be and often are affected by many factors intrinsic to the worker. Some of these factors included
Assuming all has gone well and none of the barriers outlined above are present the internal drivers that will influence a successful return to work outcome include:
After 12 months in the NSW workers system even the most resilient, motivated workers are likely to find their life situation stressful, particularly if their injury has not recovered or nearly recovered. By 12 months most injured workers are likely to have experienced:
- Financial difficulties due to pay not arriving on time, pay not taking into consideration real preinjury earnings, upfront costs such as for medications or travel not reimbursed in a timely manner.
- Delays in approvals for specialist referrals, investigative tests or new treatments
- Conflicts between stakeholders over treatment issues - such as what is “reasonable and necessary”, work capacity
- Bullying by stakeholders, or “perception” of bullying by stakeholders particularly agents, some rehabilitation providers and some employers
- Communication breakdown between parties particularly when the desired outcome of increased job capacity doesn’t occur and there is a perception that one or more parties are not working efficiently or encouraging malingering.
- Resultant stress on the injured worker and other stakeholder
- Secondary depression experienced in the injured worker
- Changes and reduction in motivation
- Secondary physical and mental health problems - anxiety depression, poor life style habits, loss of physical activity, diet, and lifestyle change, social avoidance, relationship conflicts.
Unfortunately for most workers who have had injuries that have meant they are still with the workers compensation system 12 or more months down the track there will have been many events and setbacks they have had little or no control over. For most people in such situations and with uncertainty about the future, there is a high likelihood of worry and associated problems with anxiety and depression.
Although there are many areas of an injured worker’s life that they may feel they have little or no control, most injured workers DO have more control and influence on their life situation than they may realise. To regain control however often requires getting support, especially initially and the result will not be instant. In the following sections the areas where control can be regained and exercised are outlined.
The worker needs a strong team - NTD, specialists, and solicitor.
The Workers compensation system has many stakeholders who have vested interests and hold opinions about the way things should be done. Some of these are enshrined in legislation or “Workcover Guidelines”. Many of the attitudes and practices of stakeholders however are not so much determined by the rules, but by beliefs, culture, training (or lack) of decision makers such as insurers NTD, specialists.
The healthiest environment for progress is one of team work and collaboration where all parties manage to agree upon and work towards common goals. The injured worker has some input into this in terms of :
Teach your patient their rights - These include right to choose:
Teach your patient their obligations
These include the need to:
Teach your patient/ client where to get help and in what situations.
These were outlined in the first information doc "Time of Injury to 1 Month". To summarise who can help for what:
Know who can’t help your client so they don’t waste your time and energy
The NTD is the first port of call for medical or treatment issues - the patient needs to let them know what is happening and of changes in theirphysical or psychological health. A doctor with good listening a communication skills is essential.
Solicitors
Help your patient/ the injured worker look after themself
1. Physical health
Prescribed Medication Use/Abuse
Non Prescribed Use/Abuse
Don’t stop physical activity
Substantial Injuries rarely affect only the injured body part. They affect the ease of performing activities of daily living and through problems such as sleep deprivation and associated depression have the effect of lowering motivation and drive to be active. As a result general physical deconditioning occurs and can lead to other health issues (such as obesity), particularly when diet and food intake regulation is neglected.
Although a physical or psychological injury often does affect the ease physical activities that can be undertaken, it is essential to maintain a reasonable level of health and fitness. Encouraging discussion with the worker's NTD or another health professional can be very helpful for coming up with options they can do despite having an injury.
Encourage your patient not to abandon their social network
People who are injured often find they can’t do things they use to do such as particular sports.. Frequently new ones have not been taken up. Hobbies and interests are often a source of meeting new people and friendships. Many injured workers who aren’t able to participate in activities they use to prior to injury haven’t taken up new activities in the first 12 months and tend to become socially isolated. Depression and anxiety can compound the tendency to social withdrawal and isolation.
Encourage your patient
2. Looking after mental health - problems and strategies