Who is investigating the multi-layered administration driving the costs of workers comp?

I refer to an earlier article stating that the Australian Medical Association (AMA) has told the NSW state parliamentary inquiry that poor administration and red tape are to blame for blowouts in the NSW workers’ compensation scheme. The AMA NSW vice president told the inquiry that benefits to the genuinely injured and disabled wouldn’t have to be cut if administration could be streamlined. And I ask myself the question who is actually investigating the mega-layered administration which is clearly driving workers compensation costs?

Who is investigating the multi-layered administration driving the costs of workers comp?

Fact is that when you have suffered a workplace injury, and even though your liability for your injury may have been accepted by the insurer, the injured worker becomes not only the suspect but also the enemy – and hundreds of thousands of dollars are spent by insurance companies just in order to mitigate their losses, by endless bureaucracy, administration and red tape. That is:  insurance companies will put the suspect and the enemy under increased scrutiny, by delaying and denying legitimate benefits (i.e. medical and like services) and by sending the injured workers to endless so called independent medical examinations (in the hope to have their injuries or capacity for work changed); utterly useless rehab service providers and repeatedly demanding the same information over and over again in order to approve or – more likely- to deny a service (i.e physio, home help, counseling etc.). The bureaucracy [administration and red tape] and attached costs involved is actually mind-boggling.

Multi-layered administration examples

Physio

Just to give you a recent example, I was not long ago asked by my treating upper limb surgeon and GP ” to have a crack at physiotherapy” in order to help me re-enlocate repeated shoulder joint dislocations or subluxations and to help unlock my shoulder blade which has recently started turning 90 degrees, with the tip of the shoulder blade literally moving into my armpit. A medical referral to a my (former) physiotherapist was subsequently made and sent to my case manager for approval.

I attended 2 physio sessions and submitted the account (I had paid for myself) to my case manager along with the medical referal (prescription) for physio and a copy of an email from my upper limb surgeon requesting I have a go at physio with a focus on scapulo-thoracic exercises.

My submitted accounts for physio were rejected and sent back to me along with a letter stating that physio is “unreasonable” for me, however,  provided I could submit them a detailed letter/report from my treaters – within 28 days- explaining the need for physio, the relationship between my injury and phsyio; why physio is reasonable, explain the gap in treatment and provide them with a detailed physio treatment plan; my case manager may review the information supplied and review her decision to deny me prescribed physiotherapy.

I emailed my case manager again and explained to her that I did not understand the need for the “additional information” (a lengthy report), given that I had undergone 7 massive but failed shoulder reconstructions; had been diagnosed barely 6 months ago with an irreparable shoulder, end stage traumatic osteo-arthritis and end stage rotator cuff failure, which requires the insertion of a reverse joint prosthetic, as detailed in my upper limb surgeon’s surgical and follow up reports, including a medico-legal report dated April describing the rapidly deteriorating shoulder status and prognosis as “dreadful”. In addition I pointed out to her that the barely 12 month old “independent medical assessment” also clearly stated that I would need “indefinite supportive and palliative care”. I attached all reports and again ensured she understood that she was denying me physiotherapy on a joint that needs an urgent prosthetic. I also pointed out to her that my former case manager had taken it upon her uneducated self to cease my physiotherapy treatments 2 years ago (even though I underwent another 2 surgeries after that and was prescribed physio!) and this explained the “gap” in treatment, as she should be aware of.

Well, it wasn’t good enough for my thick case manager stated she needed a new report/letter from my treaters explaining the mechanics of my initial worklplace injury (8 years ago); my injury status; the relationship between my injury and physio, why physio would be reasonable etc.

So even though I sent her recent pictures of my shoulder, the reports and the referral letter for physio and that she has – indeed- more than enough hard evidence [I am talking about more than 50 medical reports] to make the decision that hey, physio is reasonable on such a severe injury, physio is still denied to me!

It is a false economy! Considering that the workcover insurer now has to pay for additional visits to my GP and surgeon (to request the report and give them a copy of all the questions that need answering); they have to pay for my transport (taxis) and for the reports that will be prepared (probably $250 each). So in order to try to deny me an entirely appropriate, reasonable and legit treatment, and not to pay for a $136 physio account, they will happily pay around $1000 all together (medical appointments, taxis, reports). So in the end my benefit will have cost them $136 but they will have spend 10 times the amount ($1000) plus hospital emergency department visits so I can have the severely painful dislocations rest 

…and then they blame “injured workers” for massive workers comp blowout costs? Think again!

Home help

Another insane example is that I was denied home help. Part of the process required an “OT assessment” (which costs money). Subsequently I requested a “senior review” after my heart had failed as well during the last surgery. Another OT assessment was undertaken and still I was denied hone help. The matter went to conciliation. This cost the insurer about $750 just on medical reports (ortho surgeon, GP, pain specialist). The conciliator eventually had to refer the matter of “home help” to a full medical panel as I wanted to have a most reasonable 2 hrs of cleaning per week rather than the 1.5 hours per fortnight offered by the smug insurance representative. Now, brace yourself, because I also had to be assessed by a psychiatrist at the medical panel (WTF!) for “home help” on this shoulder, as well as by a panel of another “3 experts”. The medical panel charges a flat fee of $5000 and this does not even include additional medical reports I submitted (and insurer paid for). The psychiatric assessment for “home help” also re-traumaitzed me half to death, having to regurgitate all the traumas that happened to me (incl. 2 near deaths). The consequence was that I suffered from a severe PTSD crisis, which needed intensive medical treatment. So the insurer now also had to pay for psychiatric and psychology services (treatment) as well as new additional medication. Again, what did I as the injured worker “benefit” out of this insane bureaucracy? And how much did the insurer pay in order to attempt to avoid having to pay for increased home help? The money they spent on this could have bought me home help for 2 or 3 years! And because of the insane delays (red tape) I found myself without much needed, medically prescribed help for an extra year, which only aggravated my physical (and emotional) condition.

This is the reality. This is how workcover “works”.

Bureaucrats fear their superiors and try desperately to impress them.
Bureaucrats suppress their humanity and sense of decency.
Bureaucrats praise their own accomplishments in order to obscure their cruelties.
Bureaucracies protect and hide the incompetent.

As evidenced just by those two examples alone, workcover insurance companies are part of the “problem” and definitely not the “solution”. They are nothing but major players in the multi-layers of bureaucracy and administration which costs the public purse (the government) a fortune within the workcover system.

I have been asking myself over and over again

  • I ask myself who on earth is investigating the multi-layered administration which is driving the workers compensation and cause “massive budget blowouts”, for which people like Barry O’ Farrell believes injured workers are responsible – given that in his uneducated opinion injured workers’ meagre benefits need to be cut even further?
  • I also ask if there are any additional team or personal bonuses being paid to insurance companies or case managers when benefits (i.e. physio, home help, counselling, surgery, MRI etc) are successfully denied to injured workers?
  • I ask whether any team or individual bonuses are being paid when injured workers are sent back to work (and as such cut off weekly pay) – regardless of their injury status (i.e. certified unfit for all work by own specialists, even IMEs)?
  • The lower echelons of workcover insurances (i.e. case managers) repeatedly and consistently call, threaten and even bully our own treating doctors and specialists ‘fishing’ for a way to have their injured patients returned to work regardless of the medical status of the injured patients – does this mean that insurance companies (and staff) receive bonuses for shunting injured workers back to work regardless of their medical condition? To me, it certainly appears that insurance companies work on a “sales man” model, where monetary incentives are given for achievements
  • Why are no questions being asked? We challenge the media to investigate and to uncover the truth
  • Like any other type of bureaucracy, it feeds of the “system” – and I ask myself why has this not been audited (and re-audited) and why is the public not informed?
  • In my experience workcover insurances recruit front line people (those working in the trenches such as case managers) who are extremely young, inexperienced, totally under-trained, who have not even basic anatomy knowledge and who lack the experience, maturity and knowledge to handle such responsibilities (such as denying vital medical care, forcing badly injured workers to work and in doing so seriously aggravating their injuries etc.) These case managers are not only unable to read our medical or case file notes; they do not acquaint themselves with our cases (i.e. the need to demand the same medical information over and over again); they have no medical training whatsoever and yet are very much involved in our medical care and are in “constant” communication (coercion) with our doctors.
  • They (case managers)  also “come and go” faster than you can change socks; and I wonder whether they are burnt out, did they leave, are they overworked, simply insufficiently trained, immature, dumb, glorified clerks or are they simply too inexperienced for this level of responsibility?
  • Insurance companies and their case managers are simply injured workers’ greatest adversaries; and should also be viewed – in my opinion – as the workers comp schemes worst enemy. How else can one explain their illogical behaviour and their reckless wasting of hundreds of thousands of precious dollars per injured worker? They are not “working” for injured workers! They do not care about our well-being. Fact is case managers rarely answer our phone calls; they only call in a harassing and intimidating manner if they are after something; they never show respect and always assume an attitude of hostility and POWER. Most are definitely very young and inexperienced, save for a few old hags whose job it is to “deal with difficult clients” (meaning finding ways to cut off benefits, services from even the most seriously injured workers).
  • Every single case manager that I have had over my 8 year ordeal demonstrated that they had not even brought themselves up to date with my case, injury and needs – again well demonstrated by repeatedly demanding (not asking) for 9costly) medical (or other) information they already had.
I/we really challenge the media and/or any supportive politician to investigate all the above – millions of dollars could be saved from the “growing workcover schemes’ deficits” simply from addressing the insane bureaucracy, administration, red tape and immature, under-trained, hostile (and possibly overworked) insurance stakeholders.

 

[Post predicated and entered on behalf of WCV]

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6 Responses to “Who is investigating the multi-layered administration driving the costs of workers comp?”

  1. Yep, all that money being spent on everything (IME’s, conciliations, Medical Panels) except the health care needs of the injured worker. I’m so sorry for all of us who have to go through this bullying time and time again. I do believe we aught to be asking our personal health professionals to pressure their professional organisations e.g. AMA to take up these issues in a public manner. This stuff is bad for us, it is also bad for our health professionals as they are being bullied and their professionalism denigrated as well. We need allies in this struggle, and who better than the people who have walked the long miles with us in regard to our health care and whatever level of recovery we can wrestle from this disgusting system.
    There is a serious conflict of interest in the Case Management system as the insurer really case manages on behalf of the employer and the injured worker has noone to fight their battles in this system.

  2. well i will go out and investigate the system but shit i know its fucked you know its fucked the but the system doesn’t know its fucked it really does but it don’t give a shit

  3. If your legitimate medical costs ever denied – dispute the decision immediately. Don’t rely upon the mercy of your case manager. It would be nearly impossible for any insurer to deny the medical claim. If this was the only problem, call Claims Assistance Service immediately.
    If the issue remains in dispute for more than 10 working days, just let me know.

    • Phil, thanks for offering your support and help. The main problem, as I see it, is that case managers (i.e. in my physio case) repeatedly refuse to provide me with a “rejection letter”.
      I refer to emails I sent to my case manager stating:”

      Should you still refuse to pay for the most reasonable physio treatments on my R shoulder, please provide me with a rejection letter so that the urgent matter can be disputed at Conciliation

      I agree that the only way is to dispute the matter i.e at conciliation (Vic) as soon as possible, for I know that begging, pleading or even sending horrible factual pics do not help. However, when I contacted the Conciliation service (ACCS-Vic) they tell me that it is a requirement to have a ‘rejection letter’ from the insurer before you can lodge a dispute.
      The problem is that, and it is obviously part of the “starve, Stall” bureaucracy- my case manager does not provide me with a rejection letter (stating physio/whatever is denied).
      In my own experience it takes ages to obtain the final rejection letter, which ten allows for a genuine dispute. They simply keep stirring the pot, demanding “additional info”, this and that, for EVER, before issuing the rejection letter (notice). For my home help for example, it took them 11 months to give me the rejection letter.
      They know that they are denying legitimate, perfectly reasonable service and I believe this is why they drag it out for so long (in the hope I/we give up)… and if you think about it, dragging out the inevitable rejection letter saves them money too, for during this entire period (sometimes 11 months) you are simply not receiving your legit “benefit”.
      This is what frustrates me the most.
      Is there any other way that the “process” can be sped up? Even though I have called WorkSafe about such a matters (incl. denied/delayed surgery; denied/delayed taxi transport etc) they also tell me that I need a “rejection letter” and the kind ones working at WorkSafe say they will “try to get a resolution – i.e. obtain the necessary rejection letter.

      Both my home help and taxi transport took over 1 year to obtain the needed “rejection letters” and by the time the matter was resolved at conciliation or panel, and I received my legit entitlements just about 1 and a half years had gone by. This is INSANE. As it leaves me (and other injured workers) who are in desperate need of prescribed medical and like services without access to these services for yonks, all the while aggravating their physical (and mental) condition.
      It’s not like many of us have the cash to pay for medical/like services from our own pocket – meaning that we’re really stuck until the convoluted matter is resolved and approval is granted.
      For my urgent physio treatments I borrowed money to pay for them! G knows how long it will take to have the accounts reimbursed….

      workcovervictim August 23, 2012 at 7:49 am
      • Oh dear, so sorry to hear that your medical entitlements were refused.

        Your case manager must have taken you very lightly while ignoring your legitimate claim. This is how our society judges us – a person begging for few hundred dollars must be very poor and it’s ok to bully such people. It would not have happened if she knew where this could lead to.

        It is terrible to learn that people now have to fight to even get a decision from an insurer – in favour or against, and even worksafe is not helping them.
        I am assuming your claim has been accepted, but medical entitlements denied.

        Next time when you contact your case manager, first get her contact details; take down her direct phone number, date and time of conversation. You will need it in future.

        While asking for reimbursement or approval – set a time for the case manager to make a decision. Normally it is 21 days from the date of claim. Make your intention clear what would be your next step if he/she does not approve it with that time limit. There are strict guidelines and penalties apply if a case manager ignores that time frame. Generally they do, but legally they can’t.

        It is sad that someone from worksafe let you down. However, the fact is – A dispute arises when two or more parties do not agree on some issue. In your case, dispute is – your case manager failed to make a decision within set time frame. It is an offence.

        If nobody is listening – and you continue to be victimised, head to your local court. Be advised the courts have their own limitations on cases which one can be registered for hearing. If your dispute is only for few thousand dollars, you are okay to proceed. Make sure to be logical, reasonable and legal – courts can only help you according to the law. If you only need a copy of the decision of your case manager, probably you don’t have to visit the court twice. Case managers can take you lightly but not to the courts. Most likely you get the decision on the very same day your case manager receives the letter from the court.
        While doing so make sure you are doing everything legal. If your physio request has been turned down, you must have some medical evidence for that purpose such as a doctor’s referral. Normally insurers are represented by high profile solicitors. Do not worry. No solicitor in the world can prove black as white.

        However, I request you to be reasonable. Your case manager is like a bank manager who decides whether he/she should approve a loan or not. It is not their money, but sometimes little bit of power goes over the head. It is our money, what we need to spend wisely so that there must be some money left when we need it most. But your health comes first.

  4. I have a sneaking suspicion that my Physio has been got at by the insurer. I was having regular physio until he let slip that they (insurer) were talking about sending clients his way for an insurance referred independent review. I know that this is where they can make more $$$ than seeing walk in’s and Dr Referred patients. I will get to the bottom of this in my own way as going through their channels usually ends up in frustration.