4.3.4 Progress reports to decide reasonableness
Progress reports are mainly used to determine whether a particular medical and like service is reasonable in terms of the nature and frequency of service. However, progress reports can be requested for a variety of reasons by the Agent or WorkSafe, employer, Conciliation Officer, Medical Panel Under the legislation, unless inconsistent with the context or subject-matter — Medical Panel means a Medical Panel constituted under Division 2 of Part 12 or solicitor.
Worker action
On their WorkSafe Injury Claim form, workers sign the authority which authorises a medical or hospital service provider to:
- provide information (including a report) about the service provided in connection with the work-related An injury/disease is work related if it arose out of or in the course of employment and the scope of employment. injury or illness
- release that information (report) to parties authorised by WorkSafe.
Agent action
Consider requesting a progress report if:
- the claim is long-term or becoming long-term
- modified duties are available and the worker’s capacity needs to be assessed
- reports from private investigators indicate that the worker is fit to return to work – whether for pre-injury or modified duties or a different time fraction
- medicine or treatment is inconsistent with the injury or illness
- there may be a more effective, alternative course of treatment for the injury or disease
- the worker is seeking an excessive level of para-medical or ancillary health services
- the level of servicing is increasing over time
- services have been provided for extended periods of time and ongoing management requires review in line with the Clinical Framework for the delivery of health services.
Send a legible copy of the worker's signed consent on their claim form to the medical practitioner who is overseeing the worker’s treatment.
4.3.5 Review ongoing entitlement
When a claim has reached 52 weeks post:
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weekly payments ceasing (full-time Full-time worker means a worker who is employed for at least the normal number of hours fixed in any industrial award applicable to the worker or if there is no applicable award the prescribed number of hours return to work or termination of weekly payments) or
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the commencement of only medical and like expenses being paid
it will undergo a medical and like entitlement review (referred to as a “52 week MLER”).
Complete 52 week MLER
When the 52 week time limit is reached, review whether:
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medical and like services should cease
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any other exceptions apply that allow medical and like service to continue.
Where a 52 week MLER review is not required
A 52 week MLER review is not required where a worker has received:
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a voluntary settlement A lump sum payment that replaces an injured worker's right to ongoing weekly compensation. under the legislation
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common law (WorkSafe or TAC Transport Accident Commission) where there is a pecuniary loss A loss of earning capacity component.
52 week MLER process
When conducting a 52 week MLER, consider if any of the following apply:
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The worker has returned to work but cannot remain at work without the service
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Surgery is required (which has not previously been approved by WorkSafe)
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The worker has a Serious Injury (SI)
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The worker requires modification of a prosthesis
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The medical and like service is essential to ensuring the worker’s health or ability to complete necessary activities of daily living does not significantly deteriorate
After considering the above, the Agent must follow the 52 week MLER process outlined in Novus to assess the ongoing entitlement of medical and like expenses.
Note: The questions in the 52 week MLER process must be answered as at the date the Agent is completing the assessment, not the date the MLER process was initiated.
Making a 52 Week MLER determination
When the 52 week MLER process identifies that an assessment is required the Agent must:
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engage all relevant parties (e.g. the worker, treating health practitioner or engaged specialist) in the development of a treatment plan for the foreseeable future and;
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negotiate agreement of the plan with the worker and the Treating Health Practitioner (THP Treating Health Practitioner).
Once the medical information has been received, reviewed and assessed, one of the below outcomes must be issued (including by revisiting the required exclusions under the 52 week MLER process above as necessary).
Medical & like services terminated or varied
If medical and like services are to be terminated or varied please refer to 4.4 Terminate medical & like services.
Medical & like services continue
If medical and like services are to continue on the claim, the Agent must ensure a Maintain Treatment letter is provided to both the worker and the engaged THP. The Agent must ensure they initiate the development of a treatment plan for ongoing medical and like services with the worker and the THP.