Xchanging denies basic home help to injured worker – a story

Yesterday, aworkcovervictimsdiary received an email from an injured worker who has been repeatedly denied basic home help by Xchanging, leaving her marooned and facing a very cold winter…The injured worker is also seeking assistance to navigate this dreadful Workcover system.

Xchanging denies basic home help to injured worker – a story

I am an injured worker and my file is currently managed by Xchanging.

My treating GP has made requests to the insurer for assistance with home help and garden upkeep.

This is slowly happening but not at the level I require, of course. After two ADL’s this year, we are now in debate about the possible recommendations an upcoming report ‘Workable’ can produce for the Insurer.

So far, by emails with Workable, I am being advised that although my adult daughter does not live at home and she works and lives 65kilometers away, the Insurer expects she is to assist me with one of the garden chores I have requested assistance with when she visits me.

She has already spent too many years helping me out, it’s time for her to get on with her own life and be happy. Her not being at home honour bound to help me is a much healthier and normal life for a 23 year old.

Also, another request my GP has made is assistance with Wood Deliveries as my Primary Source of Heating is a Combustion Heater in the Lounge room.

Wood collecting was another chore my daughter assisted with. I have been advised by Workable that this assistance is unlikely to occur because I am unlucky enough to have a small gas heater in the Dining Room.

I am expected to use this to keep warm through Winter although this heater barely provides enough heat to warm the room it is in due to the small size of the heater (it’s not a wall furnace) and open plan design. It is also meant to be only a supplementary heating source to the Combustion Heater. Historically we have always used Wood and the Combustion Heater for heating but this is of no consequence in this instance.

At this stage of discussions, it would appear that Xchanging expect me to spend Winter bunkered down in the Dining Room to try to keep warm rather than use my Loungeroom, my key living area, as I would normally do in winter.

I have pointed out to both parties I am rather glad the Workable Assessor didn’t notice the ceiling heater in the Bathroom as I get bad visuals at the prospect of spending winter in there to keep warm as an alternative. I am awaiting a reply on this matter.

There are other issues pertaining to the assistance requests but they are too lengthy to put in this message but I am happy to provide them to someone who is able to assist me to navigate this dreadful Workcover system. Any help would be appreciated.

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Unfortunately this an all too common scenario. The way WorkSafe (and basically all workcover authorities) and, in particular, the way the workcover insurers interpret the act (legislation) is set up in such a way that any excuse will be used not to grant you household help in terms of “labour”. Workcover and their agents will indeed use your family members and expect it reasonable that your own spouse, kids, mother, grandfather etc. will take care of you and of the household tasks.

Also, one must remember that so called “rehab service providers” and, in particular OT’s, are in fact chosen because they “will not cut off the hand that feeds them”. What this means is that the “independent” assessments and reports you undertake an receive from OT’s (i.e. home help assessment) will be extremely biased and will heavily focus on “keeping you independent”.

We have been told that many initial OT assessments will be “corrected” (fiddled with) by the workcover insurer (i.e. case manager) as to come to a “favourable agreement”.

In June 2011 Lisa’s own medical treaters requested urgent home help for her, based on the fact that she has lost all function in her dominant arm. She underwent 7 major surgeries and is now in need of a reverse shoulder prosthesis.

The OT’s initial assessment recommended that Lisa NOT be provided with manual home help, and instead recommended things like a long handled toilet brush (WTF), a suction brush to stick on the sink so she can was dishes left handed (WTF), a steam mop which she is unable to even ready (i.e fill water canister, add mop to the device) or maneuver and a long handled bathroom tile scrubber (of which the picture as reported in the assessment report, shows a lady using 2 hands to use it!).

Now, Lisa is not even able to get dressed on her own, to shower unassisted, to cook (at all) and even to eat meals without assistance. They[Xchanging] even provided her with a fork and knife in one (as special utensil for disabled people so they can eat with one utensil) and a plate guard so she does not spill her food (off her plate) whilst eating.

In December 2011, Lisa underwent an arthroscopy and some major debridement of her right shoulder, however, she suffered very severe heart failure during the anaesthetic. An urgent request was made to Xchanging to review their initial decision to deny home help, but guess what, home help was DENIED again!

So here we have a severely injured worker (in need of a shoulder prosthesis)a and in severe heart failure, yet Xchanging deems it “inappropriate” for Lisa to have home help (and taxi travel)!

Snippet from the OT home help assessment:

 

Rejection letter Xchanging

Subsequently, Lisa – in a desperate situation – had no option but to appeal Xchanging’s most unreasonable decision to still deny her basic home help at Conciliation. Lisa’s lawyers had also advised her that if she would not be successful at ACCS, the matter would be fought all the way in a court of law!

In March 2012 (almost 1 year since urgent home help was requested) Lisa was able to dispute the matter at conciliation and with the assistance of WorkCover Assist, won 2 hours per fortnight of home help (as in cleaning services).

Lisa and her team wanted a more reasonable 2 hours per week, however Xchanging refused, and as such the Conciliator has forwarded the matter (the question for 2 hours per week rather than per fortnight) to the Medical Panel. Lisa is currently waiting for her appointment with the Panel.

For more info about conciliation click here>>

In the meantime Lisa is receiving 2 hours per fortnight home help. However, it took Xchanging no less that 54 days after Conciliation, to get the “paperwork” straight (they breached ACCS ruling) and over 60 days to organise the first cleaning service, which Lisa only just received this week!

So all in all it took Lisa almost a full year to obtain basic household help – not at the level required- after an urgent medical request was made.
To say that our workcover system is sick is an understatement. It enrages us to hear and read such a stories, especially during at time where the need for “slashing of workers compensation benefits” is plastered all over the media. Fact is injured workers do NOT get their legally entitled “benefits”.

The workcover insurance companies are a for-profit business and all and any”benefits” are routinely denied, even to those severely injured workers who are in desperate need. They are trained in the art of bullying, intimidation and denial and will make all injured workers fight for their meager “entitlements”.

Look at it this way: in Lisa’s case Xchanging happily forked out at least $7500 ($5000 medical panel, $2500 ACCS including medical reports and assessments) to DENY her the much needed and basic home help she requires. Now tell me, how many hours of cleaning service could $7500 pay for?

But it is injured workers’ fault that the workers compensation schemes are in deficit?! In what world do we live in?

 

Home help – household help in Victoria

Source and more info: Online Claims Manual (vic)

Workers are entitled to be compensated for the reasonable costs of personal and household services incurred because of the work injury and sets out how WorkSafe determines the type of services it will accept for payment (The Act ref S5).

Household help refers to the provision of services for basic and routine common housework and gardening tasks that the worker performed pre-injury and are essential for maintaining the worker in the home.

Services should be provided to help the worker’s recovery, rehabilitation and return to work and should be appropriate to the workers injury, stage of recovery, including their physical rehabilitation program and household circumstances.

Household help assistance is also supported by authorised occupational therapy services, provided by an OT in order to maximise a worker’s independence with household help activities.

The legislation also specifies that these services must be provided by a person who is approved by WorkSafe.

The following section outlines the requirements of the legislation and WorkSafe’s policy regarding compensation for household help.

Provision of services

What WorkSafe will consider paying for

Criteria for approving household help Household help should only be approved where the:

  • worker has a clear entitlement·
  • requested service is a household help service
  • request is medically endorsed
  • cost of the service is reasonable and necessary in the circumstances
  • reasonable contribution of family/household members has been considered
  • service is provided by an approved household help provider.
The worker has a clear entitlement The agent must ensure that the request is related to the worker’s work injury.
The requested service is a household help service The service that is being requested must be one that WorkSafe provides assistance for.See:20.10.3 – Checklist for housework services20.10.5 – Housework tasks service authorisation list20.10.4 – Checklist for gardening services20.10.6 – Gardening tasks service authorisation list
The request is medically endorsed A referral is required from the worker’s treating medical practitioner. The treating medical practitioner must provide supporting evidence of:

  • the nature of injury, severity of injury and any functional limitations·
  • the relationship of the work injury to the ability to perform the requested services
  • the functional limitations arising from the injury
  • the anticipated duration of functional limitations
  • any pre-existing or impacting medical conditions or household circumstances.
The cost of the service is reasonable and necessary in the circumstances The agent must assess the worker’s individual circumstances to determine whether the:

  • cost of the service is reasonable
  • service is necessary given the worker’s circumstances.
  • Agents should consider the following when assessing whether a service is necessary:
  • the relationship of the injury to the requested services
  • whether the service is for the worker
  • whether the worker undertook the tasks pre-injury
  • the worker’s ability to undertake the tasks post injury
  • the size of the worker’s home/garden at the time of the injury
  • the worker’s family circumstances
  • the contribution of family/household members.
OT to maximise worker’s independence OT services should be used to maximise the worker’s independence using:

  • adaptive techniques or equipment
  • changes to work methods. For example: self-pacing tasks throughout the day.

These should be implemented before the use of labour hire service provision.

The reasonable contribution of family/household must be considered WorkSafe expects that household members will assist with the running and maintenance of the household. Consideration must be given to the reasonable contribution of all household members in:

  • completing household tasks
  • assisting the worker to complete tasks.

When assessing contribution from family/household members their ability and maturity to complete tasks without risk to their health or safety must be considered.

Providers must be approved by WorkSafe WorkSafe will only pay the reasonable costs of services where the service provider is approved by WorkSafe prior to the service commencing.To be eligible for approval, service providers must provide WorkSafe with evidence of:

  • Australian company or Victorian business registration
  • hold current public liability insurance cover ($2 million minimum).

Household services must be provided in a professional manner, so that the interests of all parties are protected.

Who can’t provide services Personal and household services provided by a friend or family member are not an approved service and cannot be paid.
WorkSafe can refuse to register providers WorkSafe may refuse to approve and register a provider if the provider or service does not meet WorkSafe requirements.

What WorkSafe will pay for

WorkSafe will consider paying for:

  • general household and gardening services
What services will be paid for? WorkSafe will generally only provide assistance for services included in:10.7.2 – Housework tasks authorisation lists and cost/service guidelines10.7.3 – Gardening tasks authorisation lists and cost/service guidelinesAgents must assess each request on a case by case basis and consider the worker’s individual circumstances. Requests for services that are not on the list must be discussed with an IMA or Technical Manager prior to approval.Note: Authorising a service does not set a precedent for future service.
Services are generally for the worker only Household help services only extend to replacing a worker’s labour in the home for routine, common, basic housework or gardening tasks associated with maintaining themselves in the home and do not extend to other adult family members.
Services may extend to other household members Household help can provide housework assistance for a household member other then the injured worker if all the following criteria are met.the household member:

  • lives in the home
  • is dependent on the worker to perform the tasks
  • is unable to perform the tasks themselves
  • there are no other adults living in the home to undertake the tasks.

 

  • provision of firewood

What WorkSafe will not pay for

WorkSafe will not pay for:

  • the cost of cleaning materials
  • food items
  • standard housework or household appliances
  • self care tasks including bathing, dressing or personal grooming
  • pet care
  • support of hobbies or personal lifestyle interests. For example: hobby farm, animal breeding or showing
  • car care
  • home or furniture maintenance including window washing, cleaning or drapes blinds or carpets
  • home modifications including painting, renovation or modification
  • property maintenance or repair including painting, watering gardens, gutter cleaning or maintaining paving
  • the cost of garden implements unless recommended by an OT as modification or assistive equipment for the  worker
  • raw materials. For example: plants or mulch
  • fees for rubbish or grass removal.

Worker requirements

What the worker needs to provide to the provider/agent For WorkSafe to pay for household help services a worker must be able to show that the service is:

  • referred by the worker’s treating medical practitioner and medically endorsed
  • required as a direct result of a compensable work related injury
  • reasonable and necessary
  • unable to be completed by a family or household member
  • provided by an approved provider.
Provider choice Workers can use the provider of their choice; however WorkSafe will only pay the reasonable costs of services when the:

  • service has been authorised prior to delivery
  • provider has been approved by WorkSafe to provide household help services.

To find out if a chosen provider is approved and has a WorkSafe provider number, the worker should ask the provider or contact the agent.

Failure to participate in a household help (OT) assessment or recommended OT services Agents will request a household help (OT) assessment to obtain further information to determine the reasonableness of a request. If a worker does not participate in the assessment, or in OT services recommended as a result of the assessment the agent may use other available information to assess the reasonableness of services.

Provider requirements

Provider Approval Household help service providers must be approved by WorkSafe prior to service provision commencing. To be eligible for approval, service providers are required to provide WorkSafe with evidence of:

  • Australian company or Victorian business registration
  • a current public liability insurance cover ($2 million minimum).

Household help services must be provided in a professional manner, so that the interests of all parties are protected.

Service authorisation All household help service provision must be for a specific time period authorised by the worker’s agent in writing prior to the delivery of service.Service authorisations will include the:

  • tasks to be provided
  • frequency of the service
  • dates the service is to be provided
  • service cease date.
What should be included on an invoice? To help prompt payment of accounts, the following information should be included on an invoice:

  • OT / household help provider’s details including name, WorkSafe provider number and ABN
  • invoice number and/or date of invoice
  • worker’s name, claim number and date of injury (where claim number is unknown the worker’s date of birth should be provided)
  • employer’s name
  • date of service(s),item code, description of each service, fee charged for service.
Payment will only be made for services that have been authorised Payment will not be made for services that:

  • have not been authorised by the agent
  • exceed tasks, frequency or dates that have been authorised.
Provider and worker notified if payment will not be made If services are provided that have not been authorised, the provider and worker will be advised that payment will not be made for those services. The service provider will also be notified that:

  • future approval for provision of services may be jeopardised
  • the matter may be referred to WorkSafe.
Household help (OT) assessment report format A household help (OT) assessment is WorkSafe’s customised household help assessment tool for use by OTs to assess a worker’s functional capacity in regard to household help activities.The assessment tool provides guidance to OTs regarding WorkSafe’s reporting and assessment expectations in regards to maximising a worker’s independence with household tasks.
What needs to be included in a household help (OT) assessment report When writing the report, an OT must:

  • relate recommendations and the report to the specific scope of the assessment request
  • complete all relevant sections of the report. Where a section is not relevant, mark it as “not applicable”
  • ensure final reports are typed, of high quality and error free
  • be objective
  • be signed and dated by the OT who completed the assessment.

The report must be submitted to the agent within 18 working days of the request.

Note: If a report does not meet the requirements set out in the Guidance Material it may be returned to the OT for amendment at the therapist’s cost.

Payment rates and fees OTs can charge a maximum of five hours for undertaking a household help (OT) assessment. The five hours includes:·         liaison with the agent, worker and their treating health provider

  • conducting the assessment
  • travel costs
  • education (where appropriate)
  • report preparation.

Additional reimbursement for travel may be granted in exceptional circumstances. The OT should discuss these circumstances with the authorised agent and seek approval prior to undertaking the assessment.

Note: Household help (OT) assessments are not an approved OR service or part thereof.

Payment only made for services provided It is WorkSafe’s policy that payment will only be made for services that are provided. If the worker fails to attend or cancels an assessment, payment will not be made unless the agent is satisfied exceptional circumstances exist. For example: If the worker repeatedly cancels appointments the agent may exercise discretion to meet some of the OT’s costs.

10.5.18.1 – Processing a request for household help

Act ref: s99(1), s99(2), s99(14)

Request received direct from worker

If the request is received directly from the worker the agent must advise the worker within 14 calendar days that:

  • the request cannot be considered without a written referral from their treating medical practitioner
  • the treating medical practitioner will be asked to provide additional information regarding their injury and the relationship to the requested services
  • where service provision has or is likely to extend beyond 12 weeks, a household help (OT) assessment must be obtained to identify strategies to assist the worker to be independent in household tasks.
Request received from treating practitioner If the request is received from the treating medical practitioner the agent must review the information provided to ensure that it is sufficient to make a decision to triage to a short term or long term strategy.If sufficient information is not provided, the agent must contact the treating medical practitioner for the relevant information. See standard letters:

  • Letter to worker- request for further information on a household help service request
  • Letter to treating practitioner requesting further information.
Reviewing material Within 14 calendar daysof receipt of the request agents must:

  • file notes on ACCtion and Novus
  • treating practitioners’ reports
  •  independent medical assessment reports
  • previous ADL/OT assessments
  •  establish that the request is for a household help service and not another type of service, for example attendant care, child care, home modifications.
Some requests should be reviewed more urgently Requests that should be reviewed more quickly include requests:

  • associated with an acute injury. For example: following emergency surgery or discharge from hospital
  • where the worker’s circumstances dictate some urgency. For example: the worker has significant incapacity, small dependent children, no family assistance.

Also see:

  • Short term assistance
  • Long term assistance
  • Worker refuses to participate in household help (OT) assessment
  • Refusal to co-operate with OT services recommended following a household help (OT) assessment

10.5.18.2 – Service provision strategy

WorkSafe has developed a service provision strategy that adopts an independence first approach.

Key features of the strategy The six key features of the household help strategy are:

  • independence first approach
  • triage
  • assessment and review
  • short term requests (1-12 weeks)
  • long term requests (12 weeks plus)
  • service benchmarks.
Independence first approach The independence first approach aims to maximise a worker’s independence in doing their own housework and gardening. This is achieved by:

  • assisting the worker to find ways to compensate for any functional limitations by the use of adaptive techniques and / or assistive equipment
  • re-educating and training the worker in adaptive housework and gardening methods.
Triage Requests are sorted into low and high risk. Short term requests are low risk and can be dealt with quickly while potential long term (high risk) claims need closer assessment.
Assessment and review High risk claims require regular reviews to ensure:

  • the service provision is appropriate to ensure an independence approach
  • any long term service provision remains appropriate, given changing injury and household circumstances.
Short term assistance strategy The short term assistance strategy is:

  • designed for workers with short term household help needs
  • appropriate in the early or acute post injury or post surgery period.

There is no need for detailed assessment for these requests.

Long term assistance strategy The long term assistance strategy aims to maximise a worker’s independence by training the worker in adaptive or assistive techniques.
Service benchmarks To help manage requests and to drive greater consistency, WorkSafe has developed tables that outline services that can be approved and the hours and frequency of service provision.

Agents must also consider the worker’s individual circumstances in applying the service benchmarks.

 

Shortlink: http://workcovervictimsdiary.com/?p=8238

 



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2 Responses to “Xchanging denies basic home help to injured worker – a story”

  1. What does it take to get basic home help? Heat failure and a mangled arm is not enough to warrant basic household help? OM(F)G! Nowadays it seems you have to be a complete quadriplegic and even then they’ll probably tell you “your family” can just care for you (and work more than full time too to support ya), or that they can use their mouth to manipulate a steam mop. I am utterly disgusted. It shows again that insurers are there to make a profit, it’s a business and therefore everything possible (even the most needed basic care) will be denied. How do those insurers work? How do they calculate their “decisions”, for surely by neglecting injured workers and by denying them even the most basic human care, they will get worse! Sicker and sicker and more and more disabled – injured at work and DISABLED by workcover!!!

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    workcovervictim3 May 18, 2012 at 12:35 pm
  2. An anonymous injured worker emailed us the following (yet another typical example of the way injured workers are treated…)

    Twelve months after a right rotator cuff repair and now having
    treatment for a tear in the left rotator cuff. I’ve just been given
    approval for home help. A “one off “garden clean for only two hours. A “one off” home clea for two hours. I had my home quoted by a private company which claimed I needed at least 6 hours in my home and 6 hours in my garden. My case manager stated “we expect that there is already someone at home to do this work. Therefore you’re only getting what’s been assessed.” When I told them what I had been quoted, I was told if I wasn’t happy with that arrangement to “pay for it myself”. The reason I asked for help in the first place was my husband unwell and now cannot do heavy physical work. Neither can my young child. I still haven’t been given any assistance. Neither have I had any written approval. This week my Dr has given me stress leave. Diagnosis acopia.

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