Another new workcover case manager and more appalling documentation

workcover-hides-evidence

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!?

Why is there no proper documentation of an injured worker’s claim file, for example a brief, chronological claim history and summary, a 90 day report or something similar and a vital to-do-list,…

…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

We firmly believe that workcover insurance companies ought to urgently review their processes for documenting and updating claim files, as to keep abreast of the injured worker’s claim and to facilitate handover to another new case manager.

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 .

This will of course only negatively impact all parties involved in the claim file, the frustrated and exasperated injured worker and perhaps the biggest adverse impact will be on the insured account!

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]



This post has been seen 544 times.

3 Responses to “Another new workcover case manager and more appalling documentation”

  1. When any of us go to conciliation, there is generally a file or files which is every contact report request payment made…. When I saw the state of mine I nearly laughed…
    Rediculous, how do they find everything…. I am an office worker, I know how to create filing systems… My filing is strained because I can’t sit/stand/lift/hole punch etc, but is still better than theirs…
    All the need to do is have a request pending page on the top of the file, pages can be added on top if required, just makes heaps of sense… Maybe keep a separate file for payments, medical reports, contacts, conciliations… which is what I have done… Admittedly I have 3 or 4 lever arch folders, and that includes my legal file as well…. but I can generally find what ever I need within seconds. Maybe some of these case managers need some sort of Admin training…..

    Thumb up 0 Thumb down 0

  2. Now here is a matter close to my heart! One of the first lessons I learnt when I was first injured was to retain a detailed file of everything I could. Every receipt, every item of correspondence, every medical report and medical certificate, and even every time I was on leave (and what I did each day while on leave). When it finally dawned on me that my haphazard record keeping was far far better than that of my employer or insurer, I was able to use what I had to successfully argue against the institutionalised idiocity of a number of case managers and “rehabilitation specialists” (read as “poor stooges told to force me back to work irrespective of my condition”).

    Later after I recovered, I took on the far from fun task of assisting a family member with a Workcover claim running through a large well known insurer (think “Care Given Useless…”). It quickly became apparent that they were not keeping adequate files and were incredibly sloppy when it came to correspondence. We received multiple letters with incorrect dates, incorrect case information, contradictory information and outright fabrications. I personally took on the task of communicating with the case manager (my family member was not in a condition to deal with the stress and had better things to focus on, like getting well!) and it quickly became apparant that they did not expect to be questioned on their sloppy work and that they resented that I insisted that mistakes be acknowledged and fixed.

    Strangely, correspondence dried up and my attempts to communicate further with the case manager failed. Email messages went unanswered and concerns went unaddressed. FOI requests made verbally were “forgotten” or ignored until they were put in writing (the rules here in Victoria state that a verbal request can be made as well as or instead of a written one) and even when put in writing, they were not adequately addressed (information was missing).

    The case manager also seemed to develop a personal vendetta against my family member and myself, as there were repeated referrals to unnecessary IME appointments and at least one IME assesment which was so poorly performed that it was essentially useless (which did not stop the insurer attempting to use/misuse it to deny liability). Eventually, the case manager overstepped the mark and attempted to cease payments after my family member failed to attend an IME appointment. The same IME appointment that had been cancelled the day beforehand with multiple verbal confirmation from the insurer. One scathing and severe complaint (on top of other previous ones about the management of the case in general) against the case manager, coupled with a request that a new case manager be appointed, was enough to finally remove the case manager who had become more of a case mismanager than anything else.

    I urge any of you out there battling the system and standing up for your rights to document everything, no matter how small. Keep all those receipts, keep records of correspondence (written and verbal) and keep a calendar of the case. They are your best weapons!

    For the record, I actually set up my own case management system at home. I kept scanned copies of all written correspondence, as well as calendars, notes, receipts and so on on an online wiki style system which we could quickly and easily access and search. Apparently this was still better than whatever system the insurer had.

    Thumb up 0 Thumb down 0

  3. I am completely screwed now because I managed to get my last horrific case manager removed. The new one I received is even worse. In a short time of him taking over my claim it has now been unreasonably cancelled with no entitlement to compensation or medical expenses. He used an IME hired gun and didnt supply them with the original investigation that permitted my claim to be accepted, which was for an exacerbation of a pre existing injury. They have just cancelled my claim on the grounds that I was already injured when I started with my current employer. DUH!!!!! Seems the problems I was experiencing are now insignificant, and the fact that I can say that is abhorrent. I have an incomplete spinal cord injury and have had that injury for over a year, have been unable to access spinal rehabilitation, occupational therapy (therefore any mobility equipment & support I need has not been approved). I have significant mobility issues, so I spend alot of my time locked up in my rental house that I can now no longer afford. And with all this crap going on I still have to try and stay as healthy as I can. I didn’t have any psychological problems before this started, now I am just proud that I keep getting up in the morning and getting into bed each night (I dont really manage to sleep though even if sedated). My solicitors say it will take 18months to get a court date to even try to get this fixed. I feel sorry for my family that they have to live with me. Unfortunately, the more I read, the more I realise I am not alone in this situation, it doesnt make it any easier to stomach though. Wouldnt it be amazing if all of our case managers just spontaneously combusted one day!!

    Thumb up 0 Thumb down 0