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
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
- 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!
- Can an independent medical examiner prevent me from getting surgery?
- Workcover claim accepted – but surgery, procedures, imaging, specialists and treatment denied
- more articles related to surgery can be found here