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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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Agent Issues after 12 months

 

Insurers / Agents are the managers, gate keepers and bean counters of the NSW Workers Compensation system.  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 have 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:

  1. The claims officer appears to have had training in injury management
  2. The agent has policies and procedures for rapid processing of all aspects of claims including wages, treatment expenses, and travel and paying wages
  3. The agent has adequate staffing levels
  4. The agent doesn’t have staff turn over every 2 to 3 months
  5. Has a positive culture - where injured workers and treatment providers are not perceived as malingers or rorters of the system.
  6. Adopts a team and collaborative management of the injured worker
  7. Cases are managed with an emphasis on injury management as opposed to claims management,  an approach that is more collaborative and less adversarial
  8. The agent has well trained and experienced staff that are making important decisions and supervising less experienced staff.

 

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 section - Time of injury to 1 month, it was mentioned that the majority of complaints made to Work cover 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

  1. The claims officer DOES NOT appear  to have had training in injury management
  2. THE AGENT DOES NOT have policies and procedures for rapid processing of all aspects of claims including  wages, treatment expenses, travel and pay reliably
  3. THE AGENT DOES NOT have adequate staffing levels
  4. THE AGENT DOES NOT has staff turn over every 2 to 3 months
  5. THE AGENT has a negative culture  -  where Injured workers and treatments providers are not perceived as malingers or rorters of the system
  6. THE AGENT DOES NOT encourage a team and collaborative management of the injured worker; rather they are directive and non-consultative.
  7. Cases are managed with an emphasis on an adversarial approach to claims management with ongoing emphasis on reducing liability
  8. THE AGENT DOES NOT have well trained and experienced staff who are making important decisions and supervising  less experienced staff


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 

 
  • Make sure medical certificate is current and forwarded, if there is a pattern of “ we didn’t get it” call the agent after faxing to ensure they have received it
  • If problem is persistent   -  i.e. more than 3 times within a 3 month period consider making a verbal complaint to a supervisor
  • If this doesn’t resolve the issue contact WorkCover’s help line
  • If further problems make formal written complaint to WorkCover and Agent’s complaint service detailing what happen and when.

Wages not paid by employer

 
  • While the goal of RTW same employer remains, the wage to the injured worker is usually paid through the employer The employer pays what they are required to pay, i.e. for the amount of hours the person is certified to work - the agent pays the remained through the employer.
  • When no pay is received it is usually necessary to call the employer initially. 
  • If the matter still isn’t resolved satisfactorily call the agent If the problems persists call WorkCover’s help line and/or speak to your solicitor
  • Some rehabilitation provider can help with issues of wages and entitlements  

 Wages do not appear correct

 
  • Discuss with agent and find out the basis of their calculations
  • If you have documentation to support what you claim is correct forward a copy to agent
  • Consider discussing with your solicitor
 

Expenses for travel to medical appointments and or medication are not reimbursed by insurer or there are extensive delays

 
  • Initially call agent and your claims manager and check that they have been received and when they will be processed
  • If payment is not forth coming consider call WorkCover

Insurer ignores a request for a procedure or support service - e.g. home help, treatment referral. 

 
  • Make sure NTD has identified the service need on medical certificate
  • Make sure NTD has made specific referral for the procedure or service
  • Make sure agent has received and on what date
  • Identify the Workcover guideline time frame agent is required to make a response
  • When that time has passed call agent and continue at least weekly for 3 occasions.
  • If there is still no response call Workcovers.support service
  • Advise your solicitor


Have a support a service or referral refused by the agent

 
  • Make sure the reasons are in writing
  • Try and find out why - often the feedback is given to the provider of the service if they make the request rather than the injured worker.
  • Attempt to get a copy of the document rejecting a service -   Discuss with service provider -  sometimes agents want more information and the onus is on the provider to forward the requested information
  • If no results  advise solicitor and ask for help

 

Agent refers for an Independent Medical Assessment and the opinion issignificantly different re management of the injury from that of the NTD and other.

 

 
  • The NTD ultimately has responsible for managing your injury and the agent can attempt to influence a course of treatment however they cannot enforce it.
  • If treatment does not appear to be progressing however “independent assessments” are sometimes arranged which aim to reassess the liability of the insurer of managing the injury and claim. Sometimes the opinion on of the Independent assessor is that the injury has now resolved, or is no longer work related is the basis of the agent declining
    the claim. All treatment and wages are then terminated.
  • Good communication between treating professionals and the agent can reduces the chance that the agent will take
    this stance. Sometime however actions are directed top down and there is very little an individual claims officer can do.
  • If a claim is declined it is sadly essential to get a legal opinion of options
 

A Work Capacity Assessment is carried out and the findings are inconsistent with your injury experiences, feedback from your treatment team from your perceivedreal work capacities and work experiences

 
  • At this point of time there is 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

 

 

Getting Approvals from the agent -  Time frames Agents and delays

 

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.

 

It worth commenting;  however, that even when a valid complaint is lodged with the agent and/or with Workcover the vigorousness  that the matter is pursued,  followed up and dealt with will determine how much attention and priority is given to the matter and what the consequences will be if there is breach.  We are interested in hearing about injuried workers and treatment providers experiences of dealing with agents and Workcover on matters of treatment approvals -  Please refer our  Questionnaire on the this subject

 

WHAT WORKCOVER NSW HAS TO SAY

 

Travelling Expenses

 

“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. “

 

Non Response to Claim Application


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 WorkCover’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); o

• 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

 

Treatment Services That Don’t Require Prior Approval

 

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).

 

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.

 

Specialist medical practitioner


The first consultation for the injury with a specialist medical practitioner, on referral by the worker’s nominated treating doctor.

 

Pharmacy

 

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.


Pharmacy items excluded from the Pharmaceutical Benefits Schedule to a maximum amount of $100.

 


X-Ray


All plain x-rays performed on referral from the nominated treating doctor or specialist medical practitioner in relation to the injury claimed and provided within one week of injury.

 

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.

 

Physiotherapy, Osteopathy or Chiropractic treatment

 

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 wereprovided 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.

 

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.

 

Psychology treatment or counselling

 

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

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.

 

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.

 

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.

 

Remedial Massage

 

No more than 5 sessions of remedial massage, where there has been no previous remedial massage therapy for the injury claimed.


The precondition to be met before the exemption applies is:

 

a) The remedial massage therapist must be WorkCover approved.

 

Hearing needs assessment

 

The initial hearing needs assessment only.

 

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.

 

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