We often wonder what the heck is going on when we’re allocated (yet another) new workcover case manager, another one who does not seem to know anything about our injury, medical treatment, capacity for work, and pending requests i.e. for surgery, home help etc. Suddenly your weekly pay is terminated, your medical and like accounts are no longer paid for, your medication is under ‘review’, and they may not even be aware that – for example- surgery has been requested.
Are our newly allocated workcover case managers dumb? Too lazy to review our file? Or is there a huge problem with the documentation system used within the insurance company?
Another new workcover case manager and more appalling documentation
What the f***k
Recently we heard from an injured worker who suffered numerous and ongoing infections (with many hospital admissions) in an indwelling feeding tube that his/her case manager denied the payment for some gauze, swabs and iodine! Hell that case manager made huge fuss about it, to the point where the injured worker contemplated yet another conciliation (at the cost of about $2000 for the insurer!). This very seriously injured worker also pointed out to the case manager that s/he had been admitted to a public hospital a dozen times over the past year for this issue, and in doing so had saved the insurer heaps of money, but that they now dispute the payment of perfectly legitimate and necessary wound care! Also, if that is not enough, this poor injured worker was immediately referred to a vocational assessment by the new case manager, even though s/he crawls around with a feeding tube in her belly!
Another seriously injured worker who had just undergone major shoulder surgery (replacement) was allocated yet another case manager, who contacted this worker asking via email whether s/he needed further surgery! Man, s/he was still in the hospital recovering!
Yet another seriously injured worker who suffers from a terrible spinal injury, has undergone 5 surgeries and suffers major and unstable psychological injury was transferred to yet another case manager, who simply refused to pay the account of her treating psychologist. Just like that… even though this injured worker had attended conciliation and a full medical panel less than 6 months prior and was issued a certificate of ongoing psychological and psychiatric treatment. This injured worker has not seen her treating psychologist (nor psychiatrist) for over 2 months now whilst she is trying to get her new case manager to promptly pay the psych account(s)!
Lazy, dumb, illiterate case manager or just plain appalling workcover file documentation?
We believe that there is a huge problem with the documentation system within the workcover insurance companies, and the practice of poor/appalling documentation of injured workers’ files undoubtedly makes the handing over of files a thousand times more problematic.
Why else are newly allocated case managers unaware of the injured worker’s status? They don’t even know the type of injury sustained (i.e. a 10 x operated shoulder will be referred to as a “bruised arm”); its compensability status; the general outlook of the injury, a basic history of the injured worker, an outstanding to-do list (i.e pending surgery request, MRI request, home help request, physio/shrink request, FOI request, referral request etc …) and a time-frame for getting these things done!?
…to which newly allocated case managers can refer prior to contacting the injured worker, and certainly prior to starting meddling with the injured worker’s ‘benefits’.
Fact is that poor claim file documentation makes the claim handling a thousand times more difficult and frustrating!
Workcover case managers and claim documentation – some tips
A brief report, preferably both on line and in a hard copy, should be available at all times, for ease of reference. The captioned injured worker’s report should contain, at least, a brief and chronological history of the injured worker (medical/surgical history, medications, conciliation certificates etc), a general outlook (i.e. treatment, pending surgery etc.), and -importantly- a to-do-list coupled with a time-frame of when to do certain things (i.e. approval surgery/treatment, outstanding paperwork, bills etc.)
In our injured opinion,this would go a long way to help the case manager’s team leader/supervisor reviewing the file and the old and the new case manager to keep moving the claim/file forward – without unnecessary interruptions.It would make all our lives easier – that of the team leader, the case manager (undoubtedly) and, especially, the injured worker who would be saved a lot of angst, stress and frustration.
We have taken the liberty to list some of the important documentation areas below which workcover insurance companies and case managers need implementing to make your and our life a lot easier!
Important documentation areas
- The injured worker’s injury description and liability decision—This is where the workcover case manager should summarise what happened to the injured worker (i.e.type of injury(ies)), the reason the claim was accepted/denied, and the relevant information on the injured worker. Apart from the correct injured worker’s demographics (age, job title, place of work, date of injury, all injuries etc), this summary should also include for example all conciliation /arbitration/court certificates for ease of reference (we mean there is really no need to deny for example physio or counseling if the matter was already successfully resolved at conciliation!)
- Medical treatment to date and what is still planned—Here all the medical treatment that has been performed to date, and what will be coming in the future should be clearly, chronologically and briefly documented. This could include past and future surgery, medication needs, physio, imaging (CT/Xray, MRI etc), injections (i.e pain treatments), referrals to specialists and IMEs, home help, rehab, vocational etc, as well as documented diagnosis and outcomes.
- Long-term medical treatment —This section could apply to long term (seriously) injured workers.This could outline things like future medical treatment needed incl. surgery (i.e. revision surgery prosthetics),the types of medications being used, pain treatment, and any other medical (and like) treatment the seriously injured worker needs in the future.
- Strategy for (dispute) resolutions—This could be in the form of a to-do list, including the (timely) dates to have these tasks completed. This could be stuff like surveillance, (another) referral to an IME (i.e. make sure you send the injured worker to the IME in a timely manner, i.e. surgery request pending), vocational assessment, having a (senior) review performed on the claim file, Medical Advisor review, Nurse review etc. Also documented should be the potential for litigation/conciliation/arbitration based on claim / benefit denial, or status of current or ongoing litigation/conciliation/medical panel etc. Needless to mention all past conciliations/arbitrations/court should be listed as to avoid denying a benefit that has already been successfully ‘litigated’!
- Concerns/barriers to recovery of the injured worker—This is where the case manager could list the medical conditions/injuries and comorbidities and how they relate/affect the injury. Examples include prior surgeries, permanent restrictions that could affect the injured worker from returning to their regular job, secondary psychological injury etc. and likelihood of (realistically) returning to work.
Needless to state that we strongly believe that if workcover insurances and case managers would implement (and update) such a straight forward outline (both electronically and hard copy in the file) it would make file handling so much easier and a hell of a lot less stressful and frustrating for the injured worker. If workcover case managers could simply outline the injured worker’s the history, their current status/condition, and future (medical) plans in one document that they can easily modify and update in the future when the file comes up for review/discussion again or is being handed over again to the next case manager. Doing this will not only help the case manager, but also their team leader/manager, and also if the claim file gets handed over to yet another case manager, they can hit the road right where the previous one left off!
Failing to use a simple outline as described above, will undoubtedly lead to very poor claim file handling, wasted money (i.e. repeat IMEs, repeat medical reports, repeat conciliation, repeat medical panel etc.), much poorer injured worker recovery (i.e. delayed surgery/treatment), and perhaps missed opportunities in general .
Has your new case manager made inappropriate comments, demands, requests? Share the stuff-ups!
[Post dictated by WCV and manually transcribed on behalf of WCV]
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