2.6.3 Weekly payment claim segments

Accepted claims for weekly payments are managed in either the 0-78 weeks, 78-130 weeks or the 130+ weeks segment. When managing claims in any of these segments, Agents are required to:

develop a claim summary with a case management strategy and
manage claim using a multidisciplinary approach.

Multidisciplinary approach

The objectives of the multidisciplinary approach are to:

evaluate the worker’s capacity to return to work based on information obtained:
no current work capacity Under the legislation, unless inconsistent with the context or subject-matter — current work capacity, in relation to a worker, means a present inability arising from an injury such that the worker is not able to return to his or her pre-injury employment but is able to return to work in suitable employment, declared training program (including catastrophic claims)
a significantly reduced work capacity
a current work capacity but with no suitable employment identified or
a current work capacity with suitable employment identified
identify RTW Return to Work barriers and goals
assess the appropriateness of current entitlements, treatment and services
identify potential entitlements such as impairment benefit and
develop strategies to manage the claim.

Use of a suitably qualified person (return to work)

A suitably qualified person (return to work) may be appointed to support the early, safe and sustainable return to work of workers.

A suitably qualified person (return to work) is appointed if this would significantly increase the likelihood of achieving a durable return to work.

Use of an IB specialist

Impairment benefits do not require a multidisciplinary approach.

However, on other claims they could be consulted if there are factors requiring advice on entitlement to IB Impairment Benefits or strategic, legal or process issues.

Objective of the 0–78 weeks segment

The main objective is to ensure that claims management is based on a high and consistent level of medical, legal and case management expertise to maximise the early, safe and sustainable return to work of workers.

See: Return to Work

Objective of the 78–130 weeks segment

In addition to the aim of the 0-78 weeks segment, the main objective of the Tail segment is the timely and appropriate application of the Capacity Test at the end of the second entitlement period.

Objective of the 130+ weeks segment

The main objective of the Long Tail segment is to regularly review a claim to ensure that the worker receives their correct entitlement to weekly payments after the second entitlement period.

2.6.3.1 Multidisciplinary approach

The multidisciplinary approach is a comprehensive and coordinated method to manage the rehabilitation and compensation aspects of a claim. It encourages active management of claims in a manner that promotes an early, safe and sustainable return to work and community activities in a cost-effective manner.

The approach is a proactive, results-oriented process that relies on Case Managers to coordinate a range of services on behalf of the worker. The focus is to ensure there is the level of support necessary to address the worker’s needs and to optimise return to work.

By using a broad range of specialist skills, such as technical and medical skills, a multidisciplinary team (MDT Multidisciplinary Team) can better identify and address the worker's needs and enable early and active intervention.

Claims for weekly payments require active management using a multidisciplinary approach.

Specialist advice

A Case Manager arranges a case conference including people who can provide specialist advice on:

legislative entitlements and legal issues - may be a suitably qualified person (technical). Advice may also be sought from a Senior Legal Manager.
treatment and rehabilitation support (may be a dedicated Injury Management Advisor The Injury Management Advisor liaises with Case Managers and stakeholders to provide expert injury management advice to support the management of a worker’s compensation claim. who can seek diagnosis and prognosis advice from a Medical Advisor)

A RTW Specialist may be required to manage a complex RTW claim.

Case manager

A Case Manager is responsible and accountable for each claim in their portfolio including:

coordinating a multidisciplinary approach to claims management
actively communicating with stakeholders and other relevant parties
managing claims for weekly payments and pay appropriate compensation
determining the ongoing right to compensation
consulting with a Medical Advisor and a suitably qualified person (injury management) about critical medical and RTW decisions.

2.6.3.2 Stakeholder contacts

Stakeholders should be contacted upon receipt of an allocated claim and before each MDT review. It is critical in establishing employer and worker expectations, clarifying their obligations in the return to work process and obtaining current information on the worker’s recovery.

Purpose

Stakeholder contact Contact involves the Agent initiating and continuing regular contact with the worker. Employer and the worker’s treating health practitioner. This develops a relationship between the parties, allowing the collective gathering of information and the relay of strategies and goals gives the Agent an opportunity to introduce themselves and help to determine if:

the worker has a compensable injury
the worker has a capacity to work
there are potential barriers for a safe and timely return to work
the employer is meeting their legislative RTW planning obligations.

Contact the employer

If possible contact the employer first. The following information should be gathered:

Nature of injury

Clarify the nature of the injury from the employer’s perspective:

ask the employer for a description of the injury, eg the worker has hurt his back and is unable to lift weights such as 15 kg boxes
ask how the injury occurred if this is not clear (to help identify liability, fraud, recovery and common law issues).

RTW planning

Find out if the worker has returned to work. If not, ask whether a RTW date is scheduled:

inquire whether the employer has consulted with the worker and their THP Treating Health Practitioner to plan return to work options
encourage the employer to undertake RTW planning that allows for modified or alternate duties if necessary and supports the worker’s early RTW. You may even consider offering to assist with developing the plan
ask if the worker has been referred to an ORP
find out if there are any industrial issues affecting the worker’s return to work.

RTW duties

Discuss the return to work options. If the worker is not at work, ask if the employer has any alternative duties available.

Contact worker

It is best if the worker is contacted after the employer.

A worker may be represented, assisted and supported at any stage of the claim, including in the consultation process of a return to work. A worker may choose any person (except a legal practitioner Legal practitioner means an Australian legal practitioner within the meaning of the Legal Profession Act 2004) to perform this function. Employers are required to notify workers of their right to be represented, assisted and supported in the return to work information they must make available to their workers.

If a worker has chosen an individual to represent, support and assist them, the Agent liaises with this person.

For more information on this obligation see: Compliance Code 3 of 4: Return to Work Information.

Workers who have returned to work

The following information should be gathered:

if the worker anticipates more time off work, and if so clarify when this will be
discuss the worker’s duties and assess the likelihood of aggravation.

Workers who are still off work

The following information should be gathered:

nature of injury - clarify the nature of the injury from the worker’s perspective
ask the worker to describe the nature of their injury and the treatment regime they are undertaking. Do they feel any benefit from it?
ask the worker what their doctor has said about the injury
RTW planning - find out when the worker expects to RTW
ascertain what the worker sees as the main barriers to returning to work
assess if there are any non injury-related issues that may hinder the worker’s ability or desire to RTW
attitude to RTW - determine the worker’s attitude towards a RTW in general and to their employer. Is there a breakdown in the employer / employee relationship? If so, what caused it?

Contact THP

After contacting the employer and worker the THP may be contacted.

Potential areas for discussion:

nature of injury - ask the doctor to confirm the worker’s injury and diagnosis (is it the same as what the worker has advised)
RTW planning - ask if the doctor sees any barriers to RTW and their opinion about when the worker is likely to be fit to RTW
RTW duties - find out if the doctor has spoken to the employer about alternative duties for the worker. If not, suggest the potential benefits of the doctor talking to the employer about the type of duties the worker is or will be, capable of undertaking
other treatment - ask whether the doctor knows if the worker is receiving any other treatment from other medical practitioners or specialists.

Potential issue

If the doctor is reluctant to engage:

advise that their patient has signed a medical authority in the worker’s claim form authorising the doctor to release information regarding relevant to the claim
forward a copy of the signed medical authority to the doctor
arrange for an injury management specialist to contact the doctor.

Note: An employer must still meet their obligation to consult with the worker’s THP even when their Agent has obtained information from the THP. Agents should keep in contact with the employer to ensure that requests for THP information on return to work matters are not duplicated.

2.6.3.3 Case summary

A case summary needs to be prepared before the case conference to document information about the claim and identify issues for discussion at the case conference.

The conference should then:

review or develop claims management and RTW strategies to achieve case goals
specify a date for review
determine the ongoing involvement of a suitably qualified person (injury management) and/or a suitably qualified person (technical) or Medical Advisor.

See: Case management strategies

Key points for the summary

Some key points for the case summary include:

Key points	For example
Nature and context of injury	occupation, age and gender of worker when and how injury occurred injuries sustained current treatment non work related injuries
Current work capacity	the worker’s certified work capacity from the certificate of capacity work capacity from medical information such as IME future work capacity as outlined from reports, certificates etc restrictions or modifications noted on certificates or in medical reports
RTW status or progression	RTW tracking according to plan RTW sustainable
Likelihood of RTW with injury employer	worker has resigned or employment terminated employer relationship breakdown non word related issues impacting return to work

Information to review

To complete the case summary use information from:

claims forms and Certificates of Capacity
case notes and stakeholder contacts
investigations and reports
previous case summaries and claims management strategies
discussions with the previous case management staff.

Impairment benefit potential

Potential for impairment benefit can be considered at any time in the life of a claim but in particular, should be considered after 52 weeks from the date of the injury.

If such a potential exists, liaise with the Agent IB Specialist.

See: Determine liability

Fraud potential

Potential for fraud can be assessed at any time in the life of a claim.

Specialist legal and legislative advice should be sought if it is necessary to investigate further.

Recovery potential

Recovery potential is assessed when a new claim is received.

See: Recovery prompt & checklist sheet

Common law potential

Claims are assessed for potential common law:

when a new claim is received
at specified times in the life of a claim.

See: Common Law

2.6.3.4 Case conference

The multidisciplinary approach in a case conference works to identify and address the worker's needs in a coordinated approach to maximise return to work and minimise scheme liabilities.

Claims should be managed with great care, urgency and diligence.

Case manager has overall responsibility

The Case Manager has responsibility for the overall management of the claim, the completion of the stakeholder contact and claims management activities.

Where a suitably qualified person (return to work) is appointed, the suitably qualified person (return to work) has responsibility for the RTW activities and outcomes.

Each conference member may be required to complete individual allocated tasks.

Case Managers can engage other conference members for advice and support.

It is preferable that the conference members are co-located to maximise communication and the effectiveness of the claims management model.

Impairment benefits claims

For a claim for impairment benefits, the Case Manager and IBS may deal with the claim.

If other factors require other team members, then a multidisciplinary approach is used.

For example Strategic, legal or process factors might require a suitably qualified person (technical), Medical Advisor or a suitably qualified person (injury management).

Claim reviews

Claim reviews, initial and subsequent, are held with the Case Manager, suitably qualified person (technical) and/or suitably qualified person (injury management). A suitably qualified person (eligibility should be involved if liability has not been determined.

A suitably qualified person (return to work) may substitute for a Case Manager. A suitably qualified person (injury management) may also be involved in an initial claim review.

Diagnosis and prognosis advice

Conference members may decide that a Medical Advisor advice is required especially for complex claims with unresolved medical and treatment issues.

Input may be sought from the Medical Advisor at any point in the life of the claim. Requests for advice from a Medical Advisor must be made in writing via one of the prescribed Medical Advisor tasks in Novus.

Actioning of referrals by medical advisors

The Medical Advisor will review the referral information, the electronic and hard copy files as part of the review process. The Medical Advisor may contact the treating medical practitioner to discuss the reason for referral.

The Medical Advisor will document a clinical summary, outcome of treating medical practitioner contact and provide written recommendations.

The case conference team will then review the recommendation and action the Medical Advisors recommendations as appropriate.

2.6.3.5 Case management strategies

Claims must have a current case management strategy. The outcome of each multidisciplinary review will be to categorise the worker into one of three groups, which require different case management strategies.

Objective of the case management strategy

The objective of the case management strategy is to provide a plan to ensure that claim liability remains appropriate and that reasonable and appropriate treatment and services are provided to the worker to achieve a sustainable return to work.

To achieve a safe and sustainable return to work, claims are systematically reviewed to identify RTW and other barriers. The RTW strategy is a vital part of the plan.

The plan includes the actions that will be taken, by whom and by when. It also addresses services that need to be undertaken, the communication arrangements and a review date.

Results focused

The case management strategy must be focused on results. It needs to be continually reviewed and modified to ensure the worker is receiving the correct entitlements, including treatment and services appropriate to their injury circumstances and beneficial for their return to work.

Determining the strategy

The outcome is to classify workers into three different groups, each based upon their current work capacity. The results will determine the strategy to be followed.

Manage the strategy

The Case Manager manages the case management strategy, including ensuring planned actions are completed and that issues are addressed by the next scheduled review.

A RTW Specialist may be allocated to manage the claim strategy for complex RTW claims.

When to review a management strategy

The management strategy is reviewed at critical milestones in the life of a claim, such as:

after liability is accepted
before the end of the first entitlement period First entitlement period, in relation to a claim for compensation in the form of weekly payments made by a worker means an aggregate period not exceeding 13 weeks (whether or not consecutive) in respect of which a weekly payment has been paid or is payable to the worker
at the end of the first 26 weeks of paid or payable weekly payments
at the end of the first 52 weeks of paid or payable weekly payments
before the end of the second entitlement period
at least every 26 - 39 weeks after the worker has exceeded the second entitlement period and is still receiving weekly payments
when there is a significant event in the life of a claim, such as the termination of the worker's employment or a change in medical diagnosis
when a decision is made by the Agent to start or discontinue the appointment of an Agent RTW Specialist.

See: Managing the entitlement periods and step-downs (3.3)

2.6.3.6 Payment profiles

Claims are automatically assigned a payment profile in line with the segment they are allocated to.

The items in the payment profile are the only types of payments that can be made on that claim.

See: Medical & Like Services

Payment limit in a profile

Payment profiles can be used to:

prevent payments past a particular date
limit payments for certain payment types to a maximum dollar value.

Modify payment profile

Agents can add, amend or remove items and amounts from the payment profile.

The profile must be based on the individual needs and circumstances of the worker.

For example, if an Agent has made a determination to:

deny a worker’s entitlement to chiropractic treatment, the Agent must review the payment profile to ensure that chiropractic items are not included in the profile to prevent these payments being made
terminate a worker’s entitlement to physiotherapy after six further physiotherapy treatments to a particular date, the Agent must modify the payment profile so that payments for that service can no longer be made from that date
limit a worker’s entitlement for a particular type of medical and like service, the Agent must add a payment limit to restrict the value of future payments for that service.

See: Pay medical & like services

Document modification

Any change to the original payment profile and/or payment limit must be documented.

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