We have put together information to keep injured or ill persons informed of what to expect.
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All employers play a crucial role in the prevention and management of workplace injuries.
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Information for Psychologists, Occupational Therapists, Nurses, Exercise Physiologists and Doctors.
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Other key stakeholders are also encouraged to provide Information and comments about issues of relevance .
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The First Month After Injury


  • Reporting an Injury or Incident. Workplace Injuries or Illnesses
 
If in the course of their work an employee becomes injured (physically or psychologically, or contracts an illness (e.g from toxic fumes), they are entitled to have the costs of their medical treatment and rehabilitation reimbursed through their employer's compulsory worker’s compensation policy. In fact, if the injury occurs at work The Federal Government's Medicare scheme or private health insurance may not cover  treatment of the injury if they are entitled to workers compensation benefits.
 
  • Circumstances of injury  
 
Sometimes it is very clear that a work place injury occurred at the workplace and was a result of something that happened had work. For example if a worker falls off a ladder while helping several workmates load or unload tiles this is an obvious  claim. There are likely to be witnesses and there may be blood or an obvious fracture.  At other times an injury may be less obvious such as with a repetitive strain injury, or a psychological injury related to bullying. These injuries may not have been witnessed by other staff or may have also have been associated with issues of performance management.
When an injury occurs and there is uncertainty as to whether it occurred at work, Questions of liability for worker's compensation claim may arise.  To minimise difficulties down the track with accessing treatment and workers compensation benefits it is important that incidents and injuries are reported to  the  employer as soon as possible.  Employers are required to have procedures for reporting incident and injuries as well as policies and procedures in place to prevent injuries (Workplace Health and Safety).
 
  • Making a claim
 
When an  injured worker sustains an injury they may require  treatment and time off work to seek medical help. With traumatic incidents medical care and treatment is a priority, and training and procedures should have been implemented to all staff in what to do when a more serious injury occurs. The next step for the injured worker is a visit to a doctor.  An employer may request a worker to see a doctor of their choice, however the worker has the right  to consult a doctor of their choice and nominate him or her to be their Nominated Treating Doctor (NTD) for ongoing management of the medical aspects of their injury.
 
  • Choosing a doctor (The Nominated Treating Doctor-  NTD)
The NTD plays a key role in the management of an injury and how a claim is managed.  He or she assesses whether an injured worker is fit for work, and in what capacity. He or she can refer to various specialists for opinions and follow up.  It is a requirement for referral to most treatment providers such as psychologists, medical specialists and surgeons, to have been referred formally by the NTD.  Insurers must (unless they have good reason) support the recommendations for specialist referrals or treatment made by the NTD.
 
The medical certificate the NTD writes is a legal document that must be adhered to by all parties.  The employer must provide documented suitable duties consistent with the doctor’s certification.  The worker must attempt to perform them or risk having their benefits suspended.  
 

The workers compensation system is complex and not all doctors are familiar with all that is required of them.  Some do not like to undertake workers compensation work at all.  It is important when an injured worker chooses a NTD they are aware of these issues and chooses a doctor who:

  1. Is experienced as a GP generally
  2. Has experience with managing compensation claims
  3. Has empathy and understanding of the issues associated with workers compensation injuries
  4. The injured worker feels comfortable with
  5. Is efficient and organised.
 
  • Being assessed by the NTD
When the injured worker visits their NTD, they  are likely to be asked to complete paper work detailing their name, address, employment, and a history of what happened concerning their injury.  Most surgeries have computer software that has relevant questions and forms to be completed by workers compensation patients.
 
The doctor should examine the worker and discuss the circumstances of their injury.  They should give feedback about what is wrong and what further investigations or treatment are likely to be needed, as well as approximate times frames for recovery if the injury is relatively minor or straight forward.
 
The doctor may need to issue a medical certificate that states the worker is unfit to work for a given period or only for selected duties. Medications may be ordered or a referral made for treatment, for example physiotherapy with a sprain injury.
 
 
  • Making a claim
 
 A copy of the workers compensation medical certificate must be given to the employer who must, within 3 days pass  it on to their workers compensation insurer, along with paperwork concerning lodgement of the new claim.  From the information provided the insurer assesses the liability status and whether they will support treatment.  Some treatments such as physiotherapy and the initial visit to the NTD do not need the approval of the insurer; however, ongoing treatment and expenses must be approved except in limited number of specific circumstances.
 
There are 3 types of claim status that can occur following claims lodgement and they include:
 
 Full liability - relatively rare when the insurer fully accepts liability for what has happened - most likely after a significant injury that was associated with an investigation by WorkCover

Provisional Liability - Liability is accepted for treatment and payment of wages, and treatment for a period of time until the claim and circumstances are fully investigated.  The claim may later be accepted in full or declined.
 
Reasonable Excuse
There are some circumstances where the costs of treatment and wages are not required to be paid because of “a reasonable excuse”.  Some examples of this may be a psychological injury claim where performance management issues over alleged poor performance or misconduct have been carried out by the employer and the employee has become distressed and reported a psychological injury.  Even though wages and treatments are not paid, the insurer is required to have the claim investigated and the workers medically or psychiatrically assessed independently . After all the evidence is collected and reviewed a decision is made about the future claim status - whether the claim is accepted or declined.
 
  • The treatment team and the rehabilitation team
 

The Treatment Team

 

After the worker has visited their NTD, tests may be ordered to clarify the nature and extent of injury or health to determine a diagnosis and the appropriate treatment plan.  The NTD is also likely to refer the worker  to a medical specialist or an allied health professional such as a chiropractor, physiotherapist or psychologist, depending on the nature and severity of the work related injury or illness.

 

These allied health professional are part of injured worker’s “treatment team”. Their focus is on providing treatment that will allow the injured person’s body or mind to heal as quickly as possible so that can return to Hteir pre-injury job.  It is worth pointing out that about 85% of all work place injuries resolve within 2 weeks, the implications being that the majority of claimants will have limited need for referrals to specialists or allied health professionals, and when and if they do, the number of treatments they require will be minimal.

 
For the remaining 15% or so of work injuries the situation surrounding the injury or treatment is likely to be more complex. The injury might be more severe or complex - i.e. incorporating both physical and psychological injuries.  There may be problems with accessing diagnostic procedures - e.g. there may be lack of approval for services by the insurer or, suitable duties may not be offered or available at your pre-injury workplace. Other personal or health issues may intrude on the progress of treatment and rehabilitation of the work related injury.
 
It is the NTD’s job to monitor the progress of the referral and treatments and make adjustments to the medical certificate and treatment plan as required.
 
The rehabilitation team
 
Where injuries are more serious or the issues associated with the injury are complex, an insurer or employer may appoint a workplace rehabilitation provider (WRP).  All WRP’s must be accredited by Workcover NSW.  
 
Initially the employer may choose a workplace rehabilitation provider - the vast majority of rehabilitation provider referrals are initiated by the insurer with whom the employer’s policy is taken out.  The providers appointed tend to be their “preferred providers” in that they usually have a contract concerning their fee structure and way of operating that is complimentary to insurer’s business model and approach to injury management.  The majority of these rehabilitation providers are medium to large in size and have offices in range of locations.
 
The doctor, worker, union, insurer or employer can initiate a rehabilitation referral, however approval must be given by the insurer. Injured  workers CAN request a provider of their choice as opposed to the one allocated by their employer or insurer..  At least 50% of the accredited rehabilitation providers are not insurer preferred providers. Their work is generated by reputation with unions, allied health, doctors, employers, and / or through reputation they have developed concerning the quality of services they have provided to injured workers in the past.
 
The workplace rehabilitation team consists of a case manager who oversees all aspects of the case.  A good workplace rehabilitation service provider will ensure a comprehensive initial assessment is undertaken.  This assessment will be holistic in that it will be used to identify all the relevant factors and issues of injury management that need to be considered to ensure a good response to medical intervention and an increased capacity to return to work. 
 
The initial assessment may identify the need for other services to help facilitate independence, treatment responsiveness, or to increase capacity to undertake preinjury work duties.  Some of the assessments that may need to be undertaken include: 
 
A workplace assessment - This assessment is usually performed by an occupational therapist that will visit a worksite and assess a range of aspects of the work environment with the view of facilitating an incident free return to work.  This may involve changing the layout of a desk or work station, or providing other types of aids that assist the injured worker carry out their work role. 
 

A functional Assessment -  This assessment is carried out by an occupational therapist, physiotherapist or exercise physiologist who explores the physical capacities a worker has in relation to specific activities they may need to carry out in their everyday life or in their work place.  It may include assessment of tolerances for repeated lifting or bending when that is a requirement of the injured worker’s job. 

 
Vocational assessment - A vocational assessment explores a workers potential job options in context of their education levels, qualifications, acquired work skills and their transferable skills after their injury limitations and work skills affected by their injury are taken in to consideration.  Consideration is also given to the labour market, training required to become competitively employable, and time frames and costs.  A good vocational  assessment will carried out on more than one day and will involve the workers input and job preferences.
 

Ongoing Case management - Only workers who are certified fit for suitable duties by their NTD can have ongoing workplace rehabilitation support.   An experienced and skilled case manager will have a natural empathy for the injured worker’s situation and for the other stakeholders and be inspirational and motivational. They will communicate and engage with all stakeholders and help to coordinate services to maximise the prospects for a safe and durable plan for the injured worker to return to “suitable employment” whether it is with the same employer or in a different job with a different employer.

 
 
  • The role of the insurer /  agent
 

The insurers, now called “agents” by Workcover NSW play key roles in the management of the Workers compensation system.  They hold the purse strings to medical and paramedical assessments and treatments, to rehabilitation access and the ability of the worker to access a weekly wage when they are injured. Over the last 5 or so years agents have been given increasing freedom in the way they manage claims to fit within their approved Workcover business model,  providing they adhere to the legislation and Workcover Guidelines concerning procedures, practices and timeframes.  Since the O’Farrell Government’s 2012 legislation  was passed their power has increased further in that the assessments they undertake on injured workers, particularly work capacity assessments are harder to challenge successfully as many of the appeal mechanisms have been watered down.

 
Some of the roles of the agents / insurers are summarised below:
 
  1. Collect premiums from employers for their compulsory  Workcover policies
  2. Calculate and adjust premiums according  to industry, occupation, and  claims history
  3. Organise relevant assessments to determine liability
  4. Provided timely information to stakeholders over issues of liability and treatment changes 
  5. Develop a coordinated injury management plan with responsibilities outlined for treatment providers and other stakeholders
  6. Pay for “reasonably necessary” medical assessments and treatments
  7. Monitor the effectiveness of treatments  -  through discussion with service providers and the organisation of “independent” assessments 
  8. Pay the injured worker a wage according to relevant legislation  and make adjustments as require by legislation to accommodate changed or specific circumstances 
  9. Monitor compliance  of workers to their “obligations” in attending specialist appointments, treatments, job searching. 

 

 

Contact with the Agent

 

Within 3 days of lodging a claim with the employer's  insurer  the employer and injured employee should  receive a response.  The case manager assigned to the  case may call to discuss the claim, and will also call the injured worker, particularly if there is some issue related to treatment - a claim number should also be assigned within this time frame.

 

It is important to understand that being assigned a claim number does not mean that a workers claim has been accepted. It merely means a claim has been registered and a decision is to be made about status.  As a treatment provider the assignment of a claim  is no guarantee that you, as a treatment provider will be paid, even in situations where formal approval is not required -  e.g.. a "reasonable excuse" claim -  refer to the preceding sections on different type of claims status. In the letter the injured worker and employer  receives from the agent, as well as a  claim number, the letter may outline a management plan and  information about  responsibilities of the various stakeholders involved in the calim -  i.e treating doctors, employer worker and agent.  It may also include information about workers entitlements to reimbursments for example they have a right to claim:

 
  1. Travel to and from medical appointments and how to do so
  2. Medicines and how to do so
  3. To receive support at home (if their injury is substantial)in the form of home help to do things such as mow the lawn, cleaning etc.
  4. To have modifications made and paid for such things as railings and showering aids or to help with food preparation and other things to help maintain independence
  5. To choose treatment providers including the rehabilitation provider to assist them back to work
 

These issues are more likely to be relevant if the worker’s injury is substantial, and (several months down the track) the worker has not progressed in their treatment and residual injury symptoms are impacting on a range of activities of daily living.

 

In the first month both the employer and worker are likely to receive correspondence from the agent on several occasions. The case manager may call the employer  and the worker to advise on  matters related to  treatment requests, or certification issues by the workers NTD.

 

The approach and professionalism of “case managers’ various greatly from agent to agent and between agents.  Some case managers are informative polite, helpful and empathetic.  Others may be ignorant, lacking knowledge and experience, prone to rudeness, or are, suspicious and generally unhelpful.  This will be discussed at some length in the section "Challenges in the Workers Compensation System"

 
 

Roles of Employers, Injured Workers and Treatment Providers in the First month After Injury 

What  the employer should be doing

 
In the first month post injury the employer should:
  • Detail the incident leading to  the workers compensation claim
  • Complete and lodge the paperwork related to the claim
  • Forward payment for wages passed on from the insurer to the worker immediately after they receive them
  • Provide suitable duties as per guidelines on the medial certificate.
  • If you have difficulties providing suitable duties, or are unsure what you should be doing, contact your agent or WorkCover for advice.   
 
What the worker is suppose to be doing   
 
To receive and continue to receive workers compensation benefits and have treatment and rehabilitation expenses paid for the worker needs to:
  1. Attend appointments with their NTD as requested
  2. Ensure your medical certificate is always up to date and forwarded to relevant parties  -  particularly the agent who is paying them
  3. Attend all referrals made by their NTD for assessments and treatment
  4. Give adequate notification of cancellation if they are unable to attend
  5. Advise their doctor or the agent of any change in circumstance -  i.e. injury status,  change of address
  6. Undertake medical assessments organised by the agent providing they are given reasonable notice and they are within a distance that can be travelled to in view of their injury limitations
  7. Participate in rehabilitation program organised by the agent or you (although a worker can elect to change providers if you are not happy with the service of the rehabilitation provider you or the agent  arranges

What  the Treatment Providers should be doing

Unless the worker's injury is serious and requiring immediate hospitalisation the majority of medical intervention in the first month  will involve the NTD.  He or she will need to consider:

  1. Otaining a detailed injury history
  2. Identifying any significant red flags requiring immediate intervention
  3. Establishing the claims status 
  4. Refering for further investigation 
  5. Refering to other specialsits or medical staff for further assessment or treatment
 

For other treatment providers the onus will be on

  1. Establishing claim details
  2. Establishing the claim status
  3. Arranging an initial assessment consultation, 
  4. Giving initial feedback to the injured woker and referring NTD about the injury status and treatment needs
  5. Developing an injury management plan 
 

The role of Workcover in the first month

 

If all parties do what they are supposed to do in the first month there shouldn’t be need for Workcover assistance. If there are problems in the following areas a worker may need to call to their assistance line to help getting things moving calls are often made:

  1. If  the  employer won’t lodge a claim
  2. If the employer doesn't appear to have a policy
  3. The injury was caused by a clear and significant occupational health and safety breach
  4. There was no response from the agent about the workers claim within 10 days
  5. The worker wasn't advised of their claim status and doesn’t receive wage payment after 2 weeks
  6. Treatment or investigations that the worker’s NTD says is reasonably necessary are ignored or refused
  7. The employer refuses to offer suitable duties consistent with the worker’s medical certificate.

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