How long will it take for workcover to approve my surgery

injured-worker-surgery

We very often receive emails from injured workers asking us how long it will take for workcover to approve their surgeon’s request for (elective) surgery. The answer is however long it will take for your dimwit case manager/  workcover insurer to decide whether your surgery is “reasonable” or not, and this -unfortunately- includes the all too often the “need for additional information” request, be it endless communication with your surgeon, or an “independent” medical opinion (IME).

How long will it take for workcover to approve my surgery

injured-worker-surgery

WorkSafe Victoria (and other state’s workcover authorities) considers elective surgery to be any surgery that is non-emergency and is requested by a surgeon.

HOW LONG WILL IT TAKE TO APPROVE MY REQUEST FOR ELECTIVE SURGERY

When your workcover insurer (i.e. case manager) receives a request for surgery, there are “certain requirements” they must meet prior to approving your requested surgery.

In order to assist them in making a (more) timely decision, the following documents should be supplied to them when submitting a request for surgery:

  • a letter from your surgeon, detailing their speciality, requesting the surgery, what type of surgery, and how this surgery is related to your accepted WorkSafe injury/claim
  • this letter must also include the clinical indication for surgery – and relevant MBS item number(s) if possible
  • the anticipated post operative plan – i.e. how long you will need time off, rehab, physio etc.
  • any prosthesis that may be required as part of the rehabilitation required from surgery

Once this information has been received, your medically untrained, totally uneducated workcover case manager will review the request. If the request is “straight forward” your case manager will be in touch to advise the outcome of the request. It is possible to get approval in 24-48 hours!

If the request is not “straight forward” (in the pathetic Agent’s opinion) your workcover insurer (i.e. case manager) may need to seek that all too common, dreaded and delaying “further information” from your treater and/or may need you to attend an independent medical examination (IME) to determine whether the surgery should be approved.

You will be notified of the outcome “as soon as” the medical information is received…. which can take months! In particular when they send you to an IME and you need to appeal their “opinion” at Conciliation, which may involve referring the matter to a Medical Panel.

WorkSafe Vic’s Process for elective surgery requests

elective surgery

  • Case manager acknowledges  request for surgery by letter  within 5 working days
  • If no further information is required:  a letter is sent to the medical practitioner and the worker advising them of the decision to approve the elective surgery request within 10 working days of receipt of the request.
  • If further information is required, a a letter is sent to the medical practitioner requesting further information within 10 working days of receipt of the request
  • Decision letters (i.e. after more information request or IME) are also sent  within 10 working days.

To read more of the “process” accompanying explanations and some time frames, please see the Online Claims Manual – Elective surgery.

Case managers play God

However, and as stated in our article entitled “Workcover claim accepted – but surgery, procedures, imaging, specialists and treatment denied “: The most frightening part, as most of you know, is that it is our medically untrained, totally uneducated workcover Case Managers clerks who make that life or death decision for us. How cool is that! They actually get to play God!

 

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One Response to “How long will it take for workcover to approve my surgery”

  1. In reply to the surgery-I had 2 failed spinal surgeries which insurer paid for but my third I had specialist ask in a letter for approval they CGU denied but due to the extreme pain I used my private health went ahead and got my multi level fusion done. took the insurer to the WCC (NSW) in 2011 and they were ordered to pay costs as deemed necessary as it is hard for them not to really in most cases.
    Not sure with all the changes but I just gave all the details to the health insurer to pursue them for there costs.
    I had to pay a gap and some other costs myself but that was all awarded, something like $115k all up which had they done the right procedure the first time they save $150k. I could go the the IAG shareholders meetings and exp-lain to the shareholders that CGU have paid at least $250k on useless things throughout my claim. yet IAG still make like 3 billion dollars a year profit or something ridiculous amybe thats the banks but it has alot of zero’s maybe $300 millon.

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