Is your requested medical care reasonable and necessary?

By WorkcoverVictim on November 1, 2011 in Case manager (follies), Entitlements, Fraud & Abuse

Workcover legislation varies quite a bit from state to state, but one thing all states have in common is the requirement that injured workers be provided all reasonable and necessary medical care. The goal of all work cover jurisdictions is indeed to return the injured worker to work, as quick as possible and to full productivity, if possible or to the level of “maximum medical improvement”. While all injured workers require reasonable and necessary medical care under the law, the difference of opinion in the law starts again when it comes to determining what is reasonable and necessary. It’s always so vague, isn’t it? Same story with the number of independent medical examinations the insurer can send you to: ‘from time to time”; “at reasonable intervals” – why can’t the act be not more specific?

The workcover insurer is obliged to pay for all reasonable medical care for a work-related accident.

Medical care includes not only doctor visits; it also includes (but is not limited to) surgery, hospital stay and care, nursing services, medication, medical equipment, appliance and aids, even gardening services and gym passes. It is however limited to what is reasonable and necessary.

Interestingly, more often than not, workcover case managers – who have little or no medical training whatsoever and who have never ever seen you- will debate or dispute what medical care is reasonable and necessary.

From my own experience and those shared from fellow workcover victims, I have noticed that there appear to be four (4) main areas where the question of “reasonable and necessary” is constantly debated:

4 Areas Where the Question of Reasonable and Necessary is Debated:

1. Special devices/aids /home help

2. Home improvements

3. Massage, hydro therapy

4. Diagnostic testing

1. Special devices/aids/home help

A question that often comes up when a workcover victim has suffered a severe injury is the need for “specialised equipment”.

Whilst the case manager is usually not going to make too much of an issue about the need for crutches or a cane by someone who recently had back surgery, the criteria certainly gets “murky” when the treating doctor states the injured worker needs a motorised wheelchair….

There are, on the market, wheelchairs from $100 to $2000, so which one is reasonable for the insurer to pay for? Well, I suppose that if the injured person is only going to need the wheelchair for a short period of time, one could hire one (and workcover can pay for it); on the other hand, if the injured person is permanently going to be in a wheelchair I believe that a powered deluxe version, with 4 speeds and capable of doing wheelies is ‘reasonable’ and necessary. But here’s the problem, you see, workcover will dispute this and will do everything possible do get you the cheapest piece of trash (which will break within months) and tell you that anything else is “unreasonable and unnecessary”.

I have personally and recently experienced a whole range of issues regarding “home appliances and aids”. First of all, six (6) months after the formal, medical (and urgent) request for home help, I was not only denied home help (“after a thorough and careful review” so they said) but, miraculously, I was offered a few home help appliances and aids as to be “independent”.

Me - in daily life

Did I tell you that the occupational therapist wrote in his report that “I would be able to clean the house over a period of 3 weeks”. Obviously (sorry, but I NEED to vent), the report conveniently omitted that I live on my own about 3 to 5 days a week (partner interstate on business), that I am unable to get dressed on my own (and therefore stay 3 to 4 days in the same clothes); that I am unable to wash the dishes (and therefore the dishes are piled up in a stinking heap in the sink); that I am unable to prepare a meal (unless it is a frozen meal that I can stick in the microwave) etc, etc.

Well, I was “allowed” to receive a few appliances (of which to date- after 6 months- I received 4 of the 8), so far these include a most inappropriate, extremely cheap, wobbly clothes drying rack, which is far too high (have you ever tried to hang up clothes on a line or rack with 1 non-dominant arm?), a long handled, 2 dollar shop-type, plastic toilet brush (do I really care about cleaning the loo? And why do I need a long handled loo brush for?); a cheap ($80) “steam mop” and a 2 dollar-shop-type long handled bathroom tile scrubber (do I really give a sh*t about scrubbing the wall tiles of my bathroom?). That’s it. I am still waiting on a “plate guard” (a $2-shop-type plastic half moon that you can put on a plate as not to spill food when trying to eat with 1 hand); a plastic “knife and fork in one” (so I can eat on my own and defacto does not need to cut my meat etc like for a child, which I find very embarrassing); a small hand-held hoover (like a bread crumb hoover) and an, what I believe-may-be-useful food preparation system made for disabled people (it’s like a wooden board with pins on it where you can stick on a piece of bread or an apple/carrot etc and actually slice it with 1 hand).

Don’t get me wrong – I am grateful for these ‘toys’ but hey, use some common sense here. I am disabled for life. I need

Me - I use a sling and a crutch

useful toys and gadgets which will last me a life time. For example an electric can opener would work wonders (so I could open cat food and beans cans); a dishwasher would be heaven so that I could actually wash the dishes and not live surrounded by dirty, stinking dishes; maybe a food chopper so that I could prepare (slice and chop) fruits and veggies for my 2 parrots (and me); and there are quite a few of really useful things for people with 1 arm at the independent living centre .

So, have you ever tried to ‘steam mop’ a floor with a non-dominant arm? I tell you, it’s virtually impossible. The ‘steam mop’ is very difficult to maneuver single handed, and you still have to somehow manage to attach the ‘mop’ to the apparatus and fill the detachable canister with water. You can’t really put pressure with 1 arm and obviously I have trouble actually cleaning the floor (add to that 2 lovely but pooping parrots). Have you tried to use a small hand-vacuum cleaner to hoover your entire house (carpets)? OMG – it sucks – NOT! And who’s making my bed? Who’s changing the linen? Who’s hanging up the washing? Who’s ironing? Who’s maintaining the garden? Who’s cooking? Who’s shopping? Have you tried pushing a supermarket trolley 1-handed? Carried a basket 1 handed AND grab items from a shelf? Who’s driving?

2. Home improvements

According to WorkCover insurers, there are “medical providers who specialise in providing favourable impairment rating reports for injured workers and their lawyers and who also want to keep the injured worker happy” !!!

So, if the injured person complains to the doctor she, because of a severe back or neck injury, is not sleeping well, and the doctor writes a prescription for a new, extra firm pillow-top mattress, should the insurer have to pay for it? The answer, according to workcover case manager (whom I have dealt with) is, “No!”

According to an “insider mole”, usually the doctor will not insist on such if the insurer denies it. ( the mole gave me one other example: In one situation, a doctor tried to justify a new mattress but the case manager arranged for a furniture rental company to provide a second hand mattress until the injured worker was at “maximum medical improvement” – although they knew that the injured person was royally disabled and permanently so! Jesus – who wants to sleep on a second hand mattress for fu*k sake????)

Futhermore, according to the mole, other favorites include workcovervictim-friendly doctors prescribing a new hot tub for an injured worker with a severe back injury, or a new Ultimate Home Gym for an injured worker to do physical therapy at home. These were of course denied and deemed medically unnecessary and unreasonable. Instead, the workcover insurer offered physical therapy, but of course after a few sessions, the physio was referred to the ‘utilisation review panel’ and ceased!!!!

3. Massage, hydro therapy

This is yet another situation where workcover case managers will vigilantly deny such medical services as not reasonable and necessary. Hey, you may has well rub yourself , like a cow, against a tree or soak and do laps in your own bath tub hey!

4. Diagnostic testing

Diagnostic testing is an area in which many case managers have difficulty determining whether the medical care is reasonable and necessary. Often it is necessary for the doctor to run various tests to determine the precise nature of the injury…. or to follow the progression of an injury.

However, very often, if testing is a duplication of testing that has already been completed — for example, a repeat MRI — the diagnostic testing can be denied as not medically necessary. If testing is for a different body part — for example the cervical MRI on an injured worker who injured his lower back — the diagnostic testing definitely will be denied as not being reasonable and necessary. (Hence, I had this whole drama obtaining ‘approval’ for an ultrasound of my leg where hamstrings were taken to be grafted in my shoulder/arm!!!).

This is absolutely disgusting and criminal. How many of us have been denied repeated MRIs?

In my own case for example, as you know, I have endured 7 major surgeries to my right shoulder and arm over a period of 5-6 years. Every 6 to 8 months after a major reconstruction, the shoulder would ‘give way’ again and additional structures would tear. This was very noticeable, i.e. the shoulder would literally hang out of it’s socket, clunk around, my entire arm and hand would be swollen and blue etc. Prior to each new reconstruction (attempted reconstruction), my surgeon obviously needed a visual in the form of a repeat MRI to see where the problem(s) were and what additional tendons etc were torn. Well, virtually each and every time the requested MRIs were DENIED. Obviously this is very convenient for the insurer, because if you don’t have black on white ‘evidence’ of further deterioration or catastrophic deterioration of injury ‘it does not exist’ right? So they then can go on and deny you surgery, deny you physio, and keep you at work too because obviously “there’s nothing wrong with you”.

Not long ago “Corruption and Greed” also posted a comment about his difficulty obtaining a repeat MRI despite his surgeon fearing that he may get paralysed because of an implant compressing on a nerve in his spine, as seen on a CT. Same story.

Currently, as you may be aware, Xchanging has REFUSED to pay for an arthroscopy of my shoulder to further evaluate a bone infection (take biospies+debridement) after some tests suggest I have a bone infection in that shoulder!!!

Whilst all workcover glossy ‘brochures’ colourfully state that the insurer will basically approve anything the medical provider determines is medically necessary, workcover insurers and case managers will most often dispute the medical necessity of an item or service at any cost, and to the injured victim’s detriment!

And then we see in the media and WorkSafe reports the long delays in case file closures and the appalling return to work rates and so forth… P-E-L-E-A-S-E!!!

According to the Accident and Conciliation Service (ACCS), most disputes relate to Medical Services!

We should never ever forget that the Workers Compensation insurance companies are in business, after all, to make a profit. One way to maximise their profits is to pay as little as they can get away with paying on each and every claim submitted. That is the workers compensation insurance case manager’s job.

If you believe that WorkCover has declined to pay for your reasonably required treatment or care , you should appeal the matter at Conciliation (ACCS).