Workcover Case Managers can over-rule advised from our best medical specialists

workcover-insurers-vultures

We came across a submission by Professional Health Partners P/L to last year’s inquiry into the NSW Workers Compensation scheme.  It reads like a nightmare for injured workers.  Sadly it accurately reflects the experience of many injured workers. Insurance companies must have thought all their Christmases had come at once when the changes went through.  There is no longer a requirement for insurers to mismanage cases because they can now cut injured workers off without any need for worrying about denying their seemingly endless treatment needs.  And once again, ‘doctor shopping’ features as a major part of their strategy.

Why workcover insurance companies are dancing in the streets

Workcover Case Managers can over-rule advised from our best medical specialists

The NSW Workers Compensation Scheme:

 General Overview:

The current scheme is unwieldy, expensive, inefficient and not meeting the needs of the employers or the injured workers. It does not meet the needs of the medical professionals trying to re-store injured workers to good health and to provide an expeditious return to the work-place.

The Scheme currently has many Insurance Companies working under the umbrella of Workcover. Each Insurance Company has its own bureaucracy, from Boards of Management to frontline office staff. They work through Case Managers (who typically have no formal medical training) and return to work coordinators. These typically work for a third party Company, and also seldom have any formal medical training.

The Case Managers, employed by the Insurer, and the Return to Work Coordinators have the right to withhold treatment recommended by specialists, or to over-rule evidence based treatment based on thorough medical knowledge.

The problem becomes more absurd in that the Insurer, Case Manager or Return to Work Coordinators often change, without notice. The Insurance Company changes with amalgamations and take-overs, or when employers change Insurers, the Case Managers seem to change within Companies without reason and it would appear that if the Return to Work Coordinator works too diligently on behalf of the injured worker then the Insurance Company replaces them with someone who works more in accord with the wish of the Insurer.

over-ruled-medical-advise

Advice from the most senior Medical Staff in the country can be over-ruled by Case Managers, and often Orthopaedic or Neurosurgery is delayed or never done on the whim of a Case Manager “who decides that it is not necessary.” Insurers regularly use Medical Advisers that are known to provide reports favourable to the Insurer.

These appear to be used to prevent reasonable care to injured workers, especially if the injury is complex,or has been ongoing for a significant period. They are often flown into an area from afar, see a large number of people in a short period of time and then leave the region.

Alternatively patients are directed to travel inordinate distances for a consultation, with all reports and radiology. They are usually advised “I am performing this examination on behalf of the Insurer and I am unable to discuss any of my findings with you.”

In the event of an adverse report this does not allow the injured worker to contest the statements effectively. It would appear that many medium sized businesses choose to pay the fees for injured workers themselves, rather than transferring the cost to the Insurance Company because the long-term penalty to the Company’s premium is much more than meeting the cost them- selves. This seems to be a ridiculous situation, but certainly it would fit with the Workcover objective of cost containment.

Insurance Case Managers and Return to Work Coordinators have a policy of returning injured workers to a work-place, even when it is impractical.

A person who works as a heavy labourer in a sawmill or a coal mine is unlikely to be able to be gainfully employed in those positions with a serious injury, yet that is exactly what is attempted. When this fails, there is often a statement in relation to retraining. But the retraining is often unrealistic. A hard working saw-miller is unlikely to be able to cope with retraining as a computer technician or as an office worker but these seem to be the first options considered.

I have been notified twice in the last fortnight that injured workers have been advised that they should seek retraining at their own expense and that on commencement of retraining they will be transferred to Centrelink payments, and their compensation would cease.

This is hardly motivation for an injured worker to attempt rehabilitation along a new career path.

 

 



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2 Responses to “Workcover Case Managers can over-rule advised from our best medical specialists”

  1. A CLASSIC, albeit a living nightmare for all of us, injured workers. Congrats on PL for having the guts to write it LIKE IT REALLY IS.

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    workcovervictim3 March 4, 2013 at 10:33 am
  2. I see a highly regarded Musculoskeletal physician, he requested a repeat RFD as I had months of reduced pain after the first one, I was also able to remain at work.
    I was sent to an IME who has written that “it is reasonable for me to have the procedure due to the benefit received prior, but he is not of the opinion it will make a significant long term benefit”. Based solely on the “no significant long term benefit” statement the repeat procedure has been denied. Conciliation is pending.
    The IME went on to say that I should have repeat MRI’s to rule out operable lesions, and that I should be sent to a spinal surgeon for an opinion on whether surgery might be considered.
    Based on the IME suggestions, should the insurer send me to a surgeon? I don’t think it would hurt for an opinion, surgery is not a real option for me as I don’t have a support network, unless they count teenage boys, neither with licences as I can’t spend the time in the car for lessons…. I haven’t been able to continue at work due to the increased pain. Its as though the insurer doesn’t care what so ever. we all know they don’t. weekly payments stopped some time ago and will only recommence if I have to have surgery.

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