The most common workcover claims handling errors

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Have you ever had a workcover insurance company or a workcover case manager apologise or even admit they made a mistake? We don’t think so! The fact is that workcover claims handling errors  are rampant and have become a serious issue, which – certainly in more civilised countries such as Canada and USA- attracts sanctions and fines against insurance companies.

The most common workcover claims handling errors

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Workcover claims management , supervisors/team leaders , and the workcover case managers make many errors in judgment, or (often) wittingly and sometimes unwittingly commit “an oversight”. The fact of the matter is that we have yet to come across a workcover insurance company, or a case manager (or team leader) who admits they have made a mistake! Even when gross mistakes are made, all an injured worker can expect is something along the lines ‘oops, it was an “oversight“‘. Even when the 6 Victorian  insurance companies were audited in 2010 by the Ombudsman and extremely serious mistakes were identified leading to fines and sanctions, not one injured worker whose claim was seriously mishandled received an apology!

Interestingly there is also no list of common workcover claims handling mistakes on any of the insurance company’s website(s), nor a directive on how to complain about a ‘mistake’.

So, we believe it is time to re-summarise what are common workcover claims handling errors seen when the workcover claims and files are audited, for example by the Ombudsman.

The most common workcover claims handling errors

Apart from rampant privacy breaches, lost documents and delayed payments stemming from poor record keeping by insurance firms, and manipulated incentive schemes the following are very common mistakes:

  • Failing to properly and thoroughly investigate the claim(s) including establishing of the nature and extent of the injuries. Case managers are extremely quick to pull the trigger and deny a perfectly legitimate claim – failing to gather all of the details before rushing to judgment!
  • Failing to properly calculate and document the average pre-injury weekly pay (PIAWE) and to properly establish the weekly pay rate! This is so so common!
  • Failing to maintain the injured workers’ files on a diary-type-document  and ensuring  regular scheduled file reviews by the case manager to ensure all needed ‘activities’ have been completed – as we mentioned earlier, poor claim file documentation makes the claim handling a thousand times more difficult and frustrating!As mentioned on our previous article, 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.
  • Failing to have or keep simple action plans – i.e. a to-do-list!
  • Failing to record in the file notes the documentation received on the (injured workers) file
  • The failure of the insurance company ‘management’ (i.e. team leader) to, at least, provide some supervision or guidance to the case manager(s) handling the claims!
  • Failing of management/team leader to maintain some sort of continuity on the injured workers’ claims by changing the assigned case manager (like undies) on the claim during the course of the claim
  • Oh and here we go, so so many case managers simply fail to read injured workers’ medical reports! Not only are case managers medically uneducated – i.e. a case manager may have studied some ‘economics’ and think they’re good for the job as they may be able to know how to save the insurance company money, but not only do they have no clue whatsoever about medical terminology, complex injuries (everything save for a fracture), but they don’t even bother reading medical reports! How is it that when you communicate with your case manager, they most often are not in the slightest aware of your current medical condition? You may have undergone 10 complex shoulder or spinal surgeries and they’ll still refer to your injury as a “bruise” or “back sprain”, not understanding that you are permanently and grossly disabled, and that you may indeed need home help or physio? Not that long ago I did not know whether I had to cry, scream or laugh when I received a letter stating that “physio is inappropriate for you” notwithstanding I had undergone 8 massive shoulder surgeries, all complicated and had a reverse shoulder prosthetic inserted… Huh? No physio?
  • Another very common mistake is that many case managers fail to know the workers compensation laws in their jurisdiction(s)!
  • Many workcover case managers also fail  to maintain contact and some sort of rapport with their ‘claimants’ (injured workers). I need not remind you of how many times your emails/letters/calls have gone unanswered and how many times, out of the blue, you may have received some “correspondence” asking you a question which you answered half a year ago, and… they never reply when you do… Fact is they don’t know you from a bar of soap, to them you are just a number.
  • Failing to file the appropriate forms with, and failing to forward/submit relevant documentation to i.e. Conciliation, IMEs and Workers Compensation Boards. (See: Workcover only provides very selective material to independent medical doctors and medical panels)
  • Failing to use Independent Medical Examinations (IME) when appropriate, and failing to send the injured worker to an IME with sufficient expertise in the field of the injured worker’s injury. Again IMEs are simply used as a tool to deny a benefit, they are used way too often (even though the legislation is pretty clear on when to use an IME), and – whats worse- just about all injured workers are sent to (geriatric) IMEs who have no expertise whatsoever in the field of injury. How often have you been sent to an “occupational physician” even though you suffer from extremely complex orthopedic injuries? Have you ever been sent to an IME Pain Specialist? Mmhh, I don’t think so!
  • Failing to use or consult with a nurse case manager when appropriate, or a medical advisor. Again case managers are not medically trained but pretend to know things better than even the best medical specialists on the planet!
  • Failing to respond to important developments on the injured workers’ claims. For example, your surgery may have broken down, or you developed a severe complication – still the case manager will ignore such turns and will for example continue to pursue your ‘vocational assessment’, or ‘rehab’. They may also send you to an IME shrink, just to make sure your deterioration is not overlapped psychologically! This happened several times to me, one such ‘incident’ still stands out where my case manager was informed by my treating specialist(s) of a major physical deterioration, however I received a letter stating – literally- that the case manager was not interested in my severe physical deterioration (only in my RTW!).
  • Another major issue is the failure to even try to return injured workers to light/suitable/modified duty work when the doctor(s) approved it! How often have we heard from injured workers who were denied a RTW, simply because their case manager was too greedy (or dumb) to organise $100-200 worth of ergonomic aides in the workplace? Or they failed to manage the “rehabber’s” lengthily and most outrageous RTW process?
  • Failing to monitor and provide timely and appropriate medical treatmentneed we say more?
  • The failure to approve related medical treatment or related body parts when introduced into the injured worker’s claim! I.e. you may develop major depression because of your (severe) injury only to have counseling denied. You may develop a complication, for example a tendon was harvested from your leg and put in your arm, the donor site became infected or suffered a permanent nerve injury, only to have all medical and related treatment to your leg outright denied on the basis that it is “unrelated’ (WTF).
  • Failing to conclude or settle claims in a timely fashion when possible!
  • Add your own case manager’s biggest blunders!

What workcover insurance companies and case managers fail to understand is that when these ‘mistakes’ (aka ‘oversights’) occur in the claims handling process, the cost of the actual claim goes up! In addition the employers who pay the premiums are also affected by these ‘oversights’, as  the severity of the claims – what the claims actually cost – also impacts their insurance premium.

 

[Post dicated by WCV and manually transcribed on behalf of WCV]

 



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3 Responses to “The most common workcover claims handling errors”

  1. I found a bit of information in the Worksafe Claims Manual while studying for conciliation.

    To be employed as an Injury Management advisor the minimum requirements are:

    As a minimum, the IMA must:

    hold qualifications in a medical, health or related area. The qualifications could include a diploma, degree or graduate diploma in medicine, health science, behavioural science, social work or rehabilitation counselling, or eligibility for registration as a nurse under the Health Practitioner Regulation National Law or
    have two years experience in workplace based rehabilitation.

    Does this mean my case manager could be getting his expert advice on my spinal cord injury from a social worker????

    If it does it would make more sense why they denied spinal rehabilitation, and instead approved 8 physio visits for me to change over from physio to a home based exercise program because that is how they expect me to manage my injury. I am an incomplete paraplegic & they only had written reports from 4 of my treatment providers confirming & grading the injury and muscle atrophy.

    But still no rehab for me.

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  2. I actually got an apology from my last case manager (Think I have a new one) for repeatedly stuffing up my transport to appointments on three occasions in a row! I was left in the cold waiting for a Taxi that didn’t turn up to take me to the IME, Fourth try they got it right. Not sure if they did this on purpose or were just extremely thick?
    On the three occasions the Taxi didn’t turn up the case manager later contacted me asking why I didn’t attend my appointment! The term “Sharp as a Billiard Ball” comes to mind.

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    • I actually received an apology in 2006 from my case manager regarding prescribed medication and it’s effect on my RTW . Case manager got very sick , was prescribed same meds as myself and realised she could not drive from the effect of medication . She phoned me to say sorry as they are only given a list of medications and their uses NOT the effects they have on function . Umm other than that WC have been bullies / rude / stressfull and totally out of order . NO idea of what the injury and it’s limitations even mean .

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