The amount of money workcover will spend on denying entitlements is insane

In the insurance world, injuries are thought of only in a financial view with short-term glasses rather than total loss costs (less expensive in the long run; greater value.) It is easily and conveniently forgotten workers sustain serious injury affecting virtually every aspect of their life. It keeps astonishing me how much money workcover and its agents will spend on an attempt to deny (or minimise) vital, basic care such as home help!

The amount of money workcover will spend on denying entitlements is insane

Workers compensation laws vary significantly 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 comp jurisdictions is to return the injured worker to full productivity, if possible and to the level of “maximum medical improvement” if the employee can not be returned to work with full productivity.

While all states require reasonable and necessary medical care, the divergence in the laws starts again when it comes to determining what is reasonable and necessary.

Given that workcover insurance companies seem to be above the law, is it a wonder that they will define virtually every medical request for a basic, necessary and reasonable treatment or service as unreasonable and inappropriate?
Let’s face it, an important rating case manager performance in workers compensation is the issue of COST. Two quantifiable generators of unnecessary costs are “frequency” and “duration” of a medical treatment or a medical-like service, such as home help. Aside from that the case manager is also rated on the major quality goal of “return to work”, but again “return to maximum or full work capacity at the least COST”.

Xchanging spending spree to deny home help – an example

It just keeps astounding me at the amount of money Xchanging (and other workcover insurers) routinely and happily forks out in order to deny a legitimate “entitlement” to an injured worker!

For example, a close friend of mine who is seriously injured to the right shoulder and arm, and whose condition and prognosis have recently been described as “dreadful” (literally) has repeatedly been denied medically prescribed basic home help by Xchanging!

A conciliation was lodged and multiple medical reports were gathered and submitted, at the cost of at least $250 per “report”. Several independent Medical examinations were also undertaken and the questions as whether my friend would need home help, as well as taxi transport, were asked. These IME assessments and reports cost up to $750 each. All medical reports as well and the independent medical reports stated that my injured friend needs ongoing and indefinite supportive care, including home help, personal care and taxi transport.

Add to that the cost of at least two occupational “assessments”. Whilst the first, heavily biased occupational “assessment” concluded that my friend should be able to wash the dishes with a “long handles brush with a sucker stuck up on the sink” [WTF!] and “clean the entire house over a period of 14 days, using a steam mop, which was to be readied by her husband as my friend was not able to attach the mop to it or to fill the water canister; and with a breadcrumb hoover” [WTF]; the second occupational assessment described that my friend needed manual home help and that it was “dangerous” to leave her unassisted.

The day of conciliation, the Xchanging representative, having no where to turn, quickly offered 1 and a half hours of manual home help per fortnight.

Now, please be realistic the Workcover Assist representative had said, how much time do YOU spent cleaning your house on average per week? Surely not 1,5 hours a fortnight only?

The cold-hearted Xchanging rep, probably under pressure from the Xchanging “boss” could only increase the home help to 2 hours per fortnight, no more AND, he said the home help entitlement was to be reviewed in September [WTF]… as if my friend’s permanent disability would miraculously fix itself by then…

Even my cleaner made an unsolicited case an a plea to increase the hours of cleaning!

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So, the Conciliator had no option but to refer the matter (the question of home help hours) to a Medical Panel!

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Now, here we have a snapshot of the amount of money Xchanging has forked out to deny my crippled friend basic home help (and this is just for the home help, we are not even talking about the taxi travel and personal care, which went through a similar process!)

Cost:

Conciliation: at least $2500 for all the medical reports

Medical Panel: flat fee: $5000

Total = at least $7500

[and does not include  some IMEs, occupational assessments x 2 and the time/hours of the medical rep.]

As you say, $7,500 would have covered a substantial amount of home help!

Medical Panel

Now, how mind-boggling is it that four (4) experts are needed to give an opinion about how many hours home help my catastrophically injured friend is “allowed” to have?!!!?

Note that to assess her home help entitlement (she asked for a most humble and reasonable 2 hours per week), she is to be assesses by:

  • a shrink [WTF – we are talking about a physical inability to clean as she has lost all function in the right, dominant arm, why does she need to be interrogated by a shrink to assess home help?]
  • a GP
  • an Orthopedic surgeon
  • an Occupational Therapist

But, none of these “experts” are visiting my disabled friend’s house…to perhaps assess the cleanliness of her house and the layout of the place…?

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What a joke! How can workcover justify such a spending, .. in a futile attempt to deny a seriously injured person legitimate, basic and most reasonable medical and like help? You would be amazed at how often this happens!

Other workcover insurer claim leakage

“Leakage” is a term used to refer to “errors in payments”, and is a major issue for workcover insurance companies. Generally “leakage” is referred to as “soft” and “hard” leakage.

Hard leakage refers to erroneous payments made on claims for example those without coverage, e.g., a claim is paid when no policy coverage or compensability exists.

Soft Leakage refers to overpayments to injured workers in wage compensation, errors in medical payments, and errors in payments to medical providers after a claim is denied or disputed.

However, there is an area that is very seldom mentioned in the “literature” and that is the major issue of workcover insurance “vendor leakage”. Vendor leakage basically involves payments to various “outside vendors” or “services” used in investigation and claims handling such as, surveillance, independent medical evaluation  and even vocational assessments.

1. Let’s for example look at surveillance

Let’s face it, in most cases surveillance does not greatly impact the outcome of a claim. Videotape of an injured worker walking around outside or running various mundane and simple errands will not impact the compensability of the claim. A workers compensation claim does not disable someone from performing most general activities of daily living. A lot of money is wasted on surveillance by insurance companies.

Figures obtained by Freedom of Information show that in 2010-11, WorkSafe (workcover VIC) spent $13.7 million watching 6675 people claiming benefits. The cost was more than $1.2 million above the previous year’s bill for watching 6217 people, but it prosecuted just 18 cases of fraud.

Even though surveillance does not influence the outcome of the claim in the vast majority of cases (99%), most insurance companies are huge proponents of using surveillance and love to waste millions of dollars to so called “verify the extent of any injury before a settlement is offered.”

Actually, our former Allianz case manager, turned informant says that …” one member of our staff was a litigation manager, he wanted to see with his own eyes that a claimant was really disabled before authorising payment of a settlement...”

Surveillance is typically very costly, and unless an employer has an inside tip that the injured worker has other employment, or there is a tip off that the injured worker is routinely breaking medical restrictions, it may not be useful. Surveillance without a purpose is considered leakage, so why are they throwing money at it?.

2. IME Leakage

Independent medical examinations (IME) are probably the most commonly used “tool” for workcover case managers, who love nothing more than doctor shop till they drop.

IMEs are supposed to be used to make a medical correlation between the objective injuries an injured worker may have, and how they relate back to the workplace injury.

Inexperienced or plain dumb (xcuse me) case managers will send an injured worker for an IME too soon, or too often. The results will shoot their defense of the claim in the foot because (depending on the scenario of course) ,the IME doctor does not have a reason to terminate ongoing medical benefits.

Depending on the state, an IME may cost anywhere from $500 and $3,000, which often does not include medical record review, adding hundreds of dollars to the total bill. Plus, costs can vary on the specialty of the doctor and the location of the IME (i.e. flown in)

In our experience, which includes many claim audits by a doctor friend,  at least one-third of IMEs are totally unnecessary. (based on a sample of 100 IMEs).

In most cases, the treating doctor(s) can easily address any concerns an case manager has regarding injury causation, and correlation of symptoms to the injury. This is usually free (Worksafe refuses to pay for tel consults and “questionnaires“)!), and it only takes the time of the case manager to draft a good letter to the treating doctor outlining the concerns.

If the treating doctor will not respond (which is rare and reasonable attempts should be made), or it appears an injured worker is being  “over-treated” for the injury, then an IME MAY be warranted.

Also, IME doctors’ reputations are sometimes a greater factor than their actual report. There are a few IMEs in Australia who write a good IME reports (i.e. “favourable”), but when judges see their names, they disregard their opinions because they are known hired guns!

Plaintiff lawyers and  law judges often see the same IME doctors again and again, and if these doctors have given poor depositions in the past or write overly-aggressive reports failing to support objective medical diagnoses, the IME report is not worth the paper it is printed on.

Yet insurance companies keep sending injured workers to know hired guns, and as such waste an incredible amount of money!

An IME may be a very useful “tool” when used properly, with the appropriate doctor, and with a cover letter written by a doctor (and not an uneducated clerk/case manager). requesting specific medical information, at the correct time it is needed. Any overuse or improper use just leads to more expense sunk into the claim for no strategic benefit.

3. Vocational assessments

When an injured worker can no longer perform their pre-injury job, case managers will often (and rapidly) bring in a vocational “expert” to “comb the job market for potential work based on the injured worker’s experience and medical restrictions”.

Again and similar to IME reports, the reputation of the vocational assessor is very important. In most litigated cases, a vocational expert is used to show the injury and subsequent permanent medical restrictions the worker has doesn’t deter him or her from any future employment. But, this argument must be made correctly!!!!

Plenty of outside factors are taken into account, including geographical location, the current job market, the injured worker’s transferable skills, and the overall chance that the injured worker will have gainful, long-term, satisfying employment within these restrictions.

You usually can’t take a man who was a welder his whole life and turn him into a greeter at a grocery store, and expect a judge to be satisfied with that.

Nevertheless, it is common practice for our uneducated case managers, who benefit from a fat bonus for returning any injured worker to work as fast as possible, to send injured workers to “a vocational”, regardless of whether the injured worker actually needs one! And, as most injured workers who have attended such a “vocational” know, it’s about a 30-45 minute “computer generated assessment” which prints out “jobs” whether they are suitable or not.

This reminds me of my own “vocational” not that long ago… I had been sacked from my nearly 10 year job at the hospital, where I continued to work for some time after my injury. I am highly educated and my last position was entirely office-based and I worked in a management role. Now first of all an IME stated in his report that I should not need and would not benefit from “a vocational” as I am “highly educated and trained”. Several other IMEs stated that “rehabilitation” would be inappropriate for me as I am seriously impaired and that a “work hardening programme” would be “useless” as the problem is of a physical (disability) nature and no amount of “hardening” would fix that.

Still, my uneducated and [xcuse me] pathetic case manager took it up on herself to send me to a “vocational”, notwithstanding that I was medically certified unfit for all work both from a physical perspective and a psychiatric perspective. I had not only just been bullied, harassed, belittled and intimidated  during my last attempt to RTW, but I had also been sacked based on my employer’s opinion that I was not able to hold down a desk job because of the severity of my impairment. I found myself seriously depressed and on the verge of ending my life. However, my case manager felt that being suicidal and medico-legally certified unfit for all work physically and psychiatric was not an “excuse” not to attend a vocational and discuss and decide my future!

Well, the vocational – generated by pressing a computer button, stated that I could work as a ward clerk…. yeah… right! So I am sacked based on my too severe impairment to be able to continue my office-based managerial job, but, add insult to injury, the “vocational guru” says I can work as a ward clerk, make coffee, dust, prepare water canisters, photocopy all day, pull and haul files and enter data on computer whilst simultaneously answering hundreds of phone calls. Good one! Oh and by the way, my transferable skills (being an intensive care nurse all my life) included working for the Minister and doing building and construction work – really nice that one!

 

So…tell me why is it that workcover and their agents happily waste millions of dollars on denying legitimate entitlements, and on totally unnecessary “vendor or service leakage” which all contribute to massive and excessive claim costs? Surely these outrageous costs could be eliminated with a more proactive system and, for example, a case manager who is open to sincerely improving the health and well-being of an injured worker?
And they are talking about a growing deficit in the workers compensation scheme(s)? Get a life!

 

[post entered by T on behalf of WCV]

 

Shortlink: http://wp.me/p1MA9G-2Sf

 

 



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4 Responses to “The amount of money workcover will spend on denying entitlements is insane”

  1. Thank you for another OUTSTANDING post – love it! And isn’t is so so true!
    The other day I had a whinge to my lawyer about something similar and he said that people would be amazed at how often this happens (as in disputes and referrals to medical panels for stupid stuff).
    My lawyer has even taken the point to sent some of their clients to your blog to express their exasperation with the system!

    I am hopeful they will eventually come to a sensible decision regarding your home help though.

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  2. I was only back to work less than three weeks after surgery when my employer requested an assessment of my working capacity. The IME wondered why my employer had asked for the review? There was very little that could be assessess at this early stage. After making a huge joke about what was requested so soon after surgery i was sent home. I call that a waste of money and completely pointless.

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  3. As Vikki-Lee posted on our Facebook page:

    “I am an injured worker with several tertiary qualifications working on a second degree, I was attacked in September 2008 now live with significant perminant impairment. I am an official family Carer for 3, I too am in need for home help. I have this recommended by several medical professionals and this is also part of dispute. A process to get some assistance, I have not got one hour of regular home help as yet. I did pay for my own for a while but true to form I am now on a weekly wage of not two hours of what would be my professional rate. This low rate does not allow for paying for home help. However Employers Mutual in South Australia said via my case manager only recognises the injured worker needing a carer, so when the Carer is injured there is no help. So much for the Carers Recognition Act. WorkCover is sending a message to me that: … if you are a Carer then do not work as there will be no assistance if you are injured at work. A Carer requiring Care is not able to be processed. The insurer will go to any length to deceive professionals to right reports in their favour to deny such services. I have noticed they do this by only referring to professionals giving old information, or minimal information not holistic of the full situation or inclusive of the entire accepted claim.”

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  4. Antonio posted on our Facebook page:
    “I had chance in the recent past to be at insurer’s premises, I was left astonished when around 10 am a waiter passed through and pushing a trolley filled with beautiful exotic fruit all ready to eat for the insure’s employees, isn’t this a 5 star service? Then the insurer pretend to save money by dodgey denying lecit claims, by asking to Doctors FAIR charges, by paying the lowest travel expenses rates in Australia, yet the rates are dated many years back!”

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