Yesterday we received the shameful story of “Severely Injured” who, rightly, describes his Xchanging case manager as a crazy ex-girlfriend who went from my ‘new best friend’ to nothing short of a stalker. She
would ring the injured worker up to 8 times a day, and berate him, scream abuse, make outrageous claims – “I am stopping your payments, its up to me, and you are getting nothing, which is what you deserve”…Sound familiar? You bet! And here is what you can do about it!
When surveillance material (e.g video) is sent —by the workcover insurer— to an Independent Medical Examination doctor (IME) or a Medical Panel for commentary/opinion/assessment, basically the surveilled injured worker is entitled, by law, to explain (alleged) “inconsistencies” between the surveillance video and the injured worker’s medical history/restriction.
You won’t believe it, but during the sheer stress and grief of having my site under DoS attack, I also faced ongoing “denial of service” – basic medical care – from Xchanging and my perceived adversarial case manager. On this occasion they denied me physiotherapy treatment, notwithstanding I suffer from an end stage shoulder which requires a joint replacement. As usual- and despite hundreds of medical reports- “additional information” was requested by my case manager to justify why physio would be “reasonable”. I obviously asked my treating GP to respond to this [outrageous] demand and, to my delight, he formulated an interesting response to my case manager. Injured workers doctors ought to follow his example and speak and stand up against the ill treatment of their injured patients by workcover agents!
Injured workers medical practitioners ought to stand & speak up against ill treatment of their injured patients by workcover agents
The workcover insurance companies are a for-profit business and all and any”benefits” are routinely denied, even to those severely injured workers who are in desperate need. They are trained in the art of bullying, intimidation and denial and will make all injured workers fight for their meager “entitlements”.
The most frightening part is that case manager’s medical knowledge is very limited to non-existent but they can make sweeping decisions that have major impact on the injured worker!
The stance of today’s Case Manager (hell- why I am even bothering to use capital letters here!) has been termed “adversarial help“, with priorities of simple cost containment set by department heads and supervisors. Not to mention the carrot on the stick – $$$ bonuses for achieving certain KPIs of course!
Letter to my Xchanging case manager written by my treating general practitioner
[Click on the image to enlarge]
Isn’t it true that if a workcover insurer (i.e. Xchanging) wants to be in the business/provision of health care to injured workers, then a more CARING attitude needs to be adopted rather than the present adversarial policy?!
Treatment of injured workers by workcover agents
Medical (and like) treatment are routinely delayed or denied away. The longer the money stays in the insurers’ pocket [and investment portfolio], the more desperate the injured workers situation becomes.
And, what’s worse, our workcover system, supposedly to protect injured workers, continues to erode away injured workers rights and benefits, without anyone noticing – except of course the employers and the workcover insurers that have brought about these changes and who profit from it insanely. Look at what’s happening in NSW!
“Starving them (injured workers) out” is the key motto and modus operandi used by workcover insurers.
Not only is workcover [the workers compensation system] not there to help, except to help stuff the deep and overflowing pockets of their workcover insurance agents, but it also routinely adds to the enormous burden to be faced by injured workers. It forces a BATTLE for medical (and like) treatment and for general weekly pay, of the very SURVIVAL of the injured worker – and at the same time that it accuses us (injured workers) of faking, exaggerating and malingering it, even the deceased worker of causing it (his/her own death).
What on earth has happened to our good ol’ Australia? A country that now allows workcover, corporation and insurers to literally throw away the lives, and the health of so many injured workers, without caring, and without fear of being exposed or being held accountable? Well, it’s called workers compensation – but I prefer the term workcover terrorism – the very system we thought was there to protect us if we were injured at work.
Workcover case managers and dirty tricks
The (medically untrained) WorkCover case manager
Never have to answer the phone – voice mail only
Do not return calls – no expiry date either
Assume no continuity of care – it appears some insurers change their case managers like underwear
Deny petty things like physio a neck pillow, 30 min massage, home help- for what? Don’t they realize how fu**ing demoralizing that is?
Can be late with payments without reason. Then don’t answer calls…
Order potentially painful Functional Capacity and other repeated”Assessments” without good reason
Order “vocation assessments” when you haven’t slept for a week, can’t see straight from the pain and are actually thinking that you may be best off dead
Always infer that you can be cut off at any time
Make promises – sometimes in writing- then change their minds
Cut people off to see what happens
Workcover insurance case managers will use any means necessary to pay out as little as possible, even on legitimate claims that involve serious injuries.
Workcover insurance case managers receive extensive training on how to save the insurance company money, and not necessarily on how to examine a claim and pay a fair settlement.
Many workcover insurance companies reward their case managers and claims managers with bonuses or promotions based on how much money that person saves the company rather than how many claims are resolved.
The claims manager/case manager accomplishes this in many ways:
Using Delay tactics: The case manager is a master of using delay tactics to wear people down. He knows that many people will at some point throw up their hands and say “enough!” and finally accept the workcover insurance company’s last offer just to be over and done with the whole stressful process.
Requesting Unnecessary Information: Another method is when the case manager makes repeated requests for “documentation” even if the information will have little or no bearing on benefit to be approved service or the amount that will be offered in “settlement”. Repeated requests for unnecessary documentation can easily frustrate people and wear them down so they’re more likely to accept a lower benefit or settlement offer.
Disputing the Medical Treatment: Another way the case manager will try to minimise your claim is to dispute or question your need for medical treatment, despite having no medical training! (and even if the treatment is prescribed by their own doctor!). Often it does not matter to the case manager that your treatment has been recommended by a reputable physician or specialist. A “triple play” is very common with doctors’ requests for medical tests such as MRIs. The insurance case manager delays response to the doctors office’s request for approval, then requests “documentation from the doctor” and then the case manager says the MRI is not necessary. Six months later, you finally get the MRI and the correct treatment. What has the delay cost you? A slow medical recovery, lots of pain, financial stress and possibly the loss of your job!
Failing to Advise an Injured Worker of All His Benefits or Any of his Obligations. The case manager doesn’t have to tell you that certain types of benefits even exist! I have never known in my 7 years on workcover a case manager to freely give this information. What is worse than not getting “fully made whole” is to lose your benefits altogether, i.e. because of time limits!
Acting as Your Friend. There are times when the case manager from hell will try to “befriend” you and make it appear that she is watching out for your interests when in fact she is not. Sometime the case manager will give you advice about the type or frequency of your medical treatment, and then decide later on not to pay for the treatment because it is “excessive.” The worst is directing you to change physicians to a “company doctor.” (i.e. a doctor who is more easily persuaded to state nothing is wrong with you and certify you fit for work.)
Making False Promises. There are times when the case manager will make promises to you that he or she knows can’t be met. For example, I know of a fellow workcover victim who was promised that the workcover insurance company would pay for her to go to TAFE course. This went on for months until the injured worker was resigning her light duty position and retiring to attend the full time TAFE courses. The problem was that the injured worker didn’t find out about the insurance company’s decision not to pay for the classes until she had resigned!
All this can have a devastating effect on someone who is severely injured and lives with chronic pain.
This jerking-around can be one of the ultimate forms of social rejection. Not only do injured people feel the pain of their mistreatment, they are now having to look at the future in a new light – one of victimisation and ongoing dread.
In the insurance world, injuries are thought of only in a financial view with short-term glasses rather than total loss costs (less expensive in the long run; greater value.) It is easily and conveniently forgotten workers sustain serious injury affecting virtually every aspect of their life. It keeps astonishing me how much money workcover and its agents will spend on an attempt to deny (or minimise) vital, basic care such as home help!
The amount of money workcover will spend on denying entitlements is insane
Workers compensation laws vary significantly from state to state, but one thing all states have in common is the requirement that injured workers be provided all reasonable and necessary medical care. The goal of all work comp jurisdictions is to return the injured worker to full productivity, if possible and to the level of “maximum medical improvement” if the employee can not be returned to work with full productivity.
While all states require reasonable and necessary medical care, the divergence in the laws starts again when it comes to determining what is reasonable and necessary.
Given that workcover insurance companies seem to be above the law, is it a wonder that they will define virtually every medical request for a basic, necessary and reasonable treatment or service as unreasonable and inappropriate?
Let’s face it, an important rating case manager performance in workers compensation is the issue of COST. Two quantifiable generators of unnecessary costs are “frequency” and “duration” of a medical treatment or a medical-like service, such as home help. Aside from that the case manager is also rated on the major quality goal of “return to work”, but again “return to maximum or full work capacity at the least COST”.
Xchanging spending spree to deny home help – an example
It just keeps astounding me at the amount of money Xchanging (and other workcover insurers) routinely and happily forks out in order to deny a legitimate “entitlement” to an injured worker!
For example, a close friend of mine who is seriously injured to the right shoulder and arm, and whose condition and prognosis have recently been described as “dreadful” (literally) has repeatedly been denied medically prescribed basic home help by Xchanging!
A conciliation was lodged and multiple medical reports were gathered and submitted, at the cost of at least $250 per “report”. Several independent Medical examinations were also undertaken and the questions as whether my friend would need home help, as well as taxi transport, were asked. These IME assessments and reports cost up to $750 each. All medical reports as well and the independent medical reports stated that my injured friend needs ongoing and indefinite supportive care, including home help, personal care and taxi transport.
Add to that the cost of at least two occupational “assessments”. Whilst the first, heavily biased occupational “assessment” concluded that my friend should be able to wash the dishes with a “long handles brush with a sucker stuck up on the sink” [WTF!] and “clean the entire house over a period of 14 days, using a steam mop, which was to be readied by her husband as my friend was not able to attach the mop to it or to fill the water canister; and with a breadcrumb hoover” [WTF]; the second occupational assessment described that my friend needed manual home help and that it was “dangerous” to leave her unassisted.
The day of conciliation, the Xchanging representative, having no where to turn, quickly offered 1 and a half hours of manual home help per fortnight.
Now, please be realistic the Workcover Assist representative had said, how much time do YOU spent cleaning your house on average per week? Surely not 1,5 hours a fortnight only?
The cold-hearted Xchanging rep, probably under pressure from the Xchanging “boss” could only increase the home help to 2 hours per fortnight, no more AND, he said the home help entitlement was to be reviewed in September [WTF]… as if my friend’s permanent disability would miraculously fix itself by then…
Even my cleaner made an unsolicited case an a plea to increase the hours of cleaning!
click to enlarge
So, the Conciliator had no option but to refer the matter (the question of home help hours) to a Medical Panel!
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Now, here we have a snapshot of the amount of money Xchanging has forked out to deny my crippled friend basic home help (and this is just for the home help, we are not even talking about the taxi travel and personal care, which went through a similar process!)
Conciliation: at least $2500 for all the medical reports
Medical Panel: flat fee: $5000
Total = at least $7500
[and does not include some IMEs, occupational assessments x 2 and the time/hours of the medical rep.]
As you say, $7,500 would have covered a substantial amount of home help!
Now, how mind-boggling is it that four (4) experts are needed to give an opinion about how many hours home help my catastrophically injured friend is “allowed” to have?!!!?
Note that to assess her home help entitlement (she asked for a most humble and reasonable 2 hours per week), she is to be assesses by:
a shrink [WTF – we are talking about a physical inability to clean as she has lost all function in the right, dominant arm, why does she need to be interrogated by a shrink to assess home help?]
an Orthopedic surgeon
an Occupational Therapist
But, none of these “experts” are visiting my disabled friend’s house…to perhaps assess the cleanliness of her house and the layout of the place…?
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What a joke! How can workcover justify such a spending, .. in a futile attempt to deny a seriously injured person legitimate, basic and most reasonable medical and like help? You would be amazed at how often this happens!
Other workcover insurer claim leakage
“Leakage” is a term used to refer to “errors in payments”, and is a major issue for workcover insurance companies. Generally “leakage” is referred to as “soft” and “hard” leakage.
Hard leakage refers to erroneous payments made on claims for example those without coverage, e.g., a claim is paid when no policy coverage or compensability exists.
Soft Leakage refers to overpayments to injured workers in wage compensation, errors in medical payments, and errors in payments to medical providers after a claim is denied or disputed.
However, there is an area that is very seldom mentioned in the “literature” and that is the major issue of workcover insurance “vendor leakage”. Vendor leakage basically involves payments to various “outside vendors” or “services” used in investigation and claims handling such as, surveillance, independent medical evaluation and even vocational assessments.
1. Let’s for example look at surveillance
Let’s face it, in most cases surveillance does not greatly impact the outcome of a claim. Videotape of an injured worker walking around outside or running various mundane and simple errands will not impact the compensability of the claim. A workers compensation claim does not disable someone from performing most general activities of daily living. A lot of money is wasted on surveillance by insurance companies.
Figures obtained by Freedom of Information show that in 2010-11, WorkSafe (workcover VIC) spent $13.7 million watching 6675 people claiming benefits. The cost was more than $1.2 million above the previous year’s bill for watching 6217 people, but it prosecuted just 18 cases of fraud.
Even though surveillance does not influence the outcome of the claim in the vast majority of cases (99%), most insurance companies are huge proponents of using surveillance and love to waste millions of dollars to so called “verify the extent of any injury before a settlement is offered.”
Actually, our former Allianz case manager, turned informant says that …” one member of our staff was a litigation manager, he wanted to see with his own eyes that a claimant was really disabled before authorising payment of a settlement...”
Surveillance is typically very costly, and unless an employer has an inside tip that the injured worker has other employment, or there is a tip off that the injured worker is routinely breaking medical restrictions, it may not be useful. Surveillance without a purpose is considered leakage, so why are they throwing money at it?.
2. IME Leakage
Independent medical examinations (IME) are probably the most commonly used “tool” for workcover case managers, who love nothing more than doctor shop till they drop.
IMEs are supposed to be used to make a medical correlation between the objective injuries an injured worker may have, and how they relate back to the workplace injury.
Inexperienced or plain dumb (xcuse me) case managers will send an injured worker for an IME too soon, or too often. The results will shoot their defense of the claim in the foot because (depending on the scenario of course) ,the IME doctor does not have a reason to terminate ongoing medical benefits.
Depending on the state, an IME may cost anywhere from $500 and $3,000, which often does not include medical record review, adding hundreds of dollars to the total bill. Plus, costs can vary on the specialty of the doctor and the location of the IME (i.e. flown in)
In our experience, which includes many claim audits by a doctor friend, at least one-third of IMEs are totally unnecessary. (based on a sample of 100 IMEs).
In most cases, the treating doctor(s) can easily address any concerns an case manager has regarding injury causation, and correlation of symptoms to the injury. This is usually free (Worksafe refuses to pay for tel consults and “questionnaires“)!), and it only takes the time of the case manager to draft a good letter to the treating doctor outlining the concerns.
If the treating doctor will not respond (which is rare and reasonable attempts should be made), or it appears an injured worker is being “over-treated” for the injury, then an IME MAY be warranted.
Also, IME doctors’ reputations are sometimes a greater factor than their actual report. There are a few IMEs in Australia who write a good IME reports (i.e. “favourable”), but when judges see their names, they disregard their opinions because they are known hired guns!
Plaintiff lawyers and law judges often see the same IME doctors again and again, and if these doctors have given poor depositions in the past or write overly-aggressive reports failing to support objective medical diagnoses, the IME report is not worth the paper it is printed on.
Yet insurance companies keep sending injured workers to know hired guns, and as such waste an incredible amount of money!
An IME may be a very useful “tool” when used properly, with the appropriate doctor, and with a cover letter written by a doctor (and not an uneducated clerk/case manager). requesting specific medical information, at the correct time it is needed. Any overuse or improper use just leads to more expense sunk into the claim for no strategic benefit.
3. Vocational assessments
When an injured worker can no longer perform their pre-injury job, case managers will often (and rapidly) bring in a vocational “expert” to “comb the job market for potential work based on the injured worker’s experience and medical restrictions”.
Again and similar to IME reports, the reputation of the vocational assessor is very important. In most litigated cases, a vocational expert is used to show the injury and subsequent permanent medical restrictions the worker has doesn’t deter him or her from any future employment. But, this argument must be made correctly!!!!
Plenty of outside factors are taken into account, including geographical location, the current job market, the injured worker’s transferable skills, and the overall chance that the injured worker will have gainful, long-term, satisfying employment within these restrictions.
You usually can’t take a man who was a welder his whole life and turn him into a greeter at a grocery store, and expect a judge to be satisfied with that.
Nevertheless, it is common practice for our uneducated case managers, who benefit from a fat bonus for returning any injured worker to work as fast as possible, to send injured workers to “a vocational”, regardless of whether the injured worker actually needs one! And, as most injured workers who have attended such a “vocational” know, it’s about a 30-45 minute “computer generated assessment” which prints out “jobs” whether they are suitable or not.
This reminds me of my own “vocational” not that long ago… I had been sacked from my nearly 10 year job at the hospital, where I continued to work for some time after my injury. I am highly educated and my last position was entirely office-based and I worked in a management role. Now first of all an IME stated in his report that I should not need and would not benefit from “a vocational” as I am “highly educated and trained”. Several other IMEs stated that “rehabilitation” would be inappropriate for me as I am seriously impaired and that a “work hardening programme” would be “useless” as the problem is of a physical (disability) nature and no amount of “hardening” would fix that.
Still, my uneducated and [xcuse me] pathetic case manager took it up on herself to send me to a “vocational”, notwithstanding that I was medically certified unfit for all work both from a physical perspective and a psychiatric perspective. I had not only just been bullied, harassed, belittled and intimidated during my last attempt to RTW, but I had also been sacked based on my employer’s opinion that I was not able to hold down a desk job because of the severity of my impairment. I found myself seriously depressed and on the verge of ending my life. However, my case manager felt that being suicidal and medico-legally certified unfit for all work physically and psychiatric was not an “excuse” not to attend a vocational and discuss and decide my future!
Well, the vocational – generated by pressing a computer button, stated that I could work as a ward clerk…. yeah… right! So I am sacked based on my too severe impairment to be able to continue my office-based managerial job, but, add insult to injury, the “vocational guru” says I can work as a ward clerk, make coffee, dust, prepare water canisters, photocopy all day, pull and haul files and enter data on computer whilst simultaneously answering hundreds of phone calls. Good one! Oh and by the way, my transferable skills (being an intensive care nurse all my life) included working for the Minister and doing building and construction work – really nice that one!
So…tell me why is it that workcover and their agents happily waste millions of dollars on denying legitimate entitlements, and on totally unnecessary “vendor or service leakage” which all contribute to massive and excessive claim costs? Surely these outrageous costs could be eliminated with a more proactive system and, for example, a case manager who is open to sincerely improving the health and well-being of an injured worker?
And they are talking about a growing deficit in the workers compensation scheme(s)? Get a life!
It is extremely important that you are aware that the workcover agent (i.e. your case manager/injury adviser) will only send very selective material in support for your injury(ies) to independent medical doctors, the medical panel, your rehab provider and even your own treating doctor.
Workcover insurers fail to disclose vital medical reports
Failure to disclose of vital psychiatric reports by Allianz to treating Doctors
A couple of days ago we received a copy of an email sent to AMS Consulting (a- ahum- leading provider of consultancy and occupational rehabilitation services) from the aggrieved father of an injured worker. The email was also cc’d to WorkSafe Vic and several people in the Vivtorian Parliament.
Mr [AMS] it has come to my son’s attention,and his treating Dr A that vital Psychiatric reports have not been disclosed from [my son] treating Dr and Lawyer for proper treatment and assessment .The numerous reports warranted by Allianz to be assessed by (IME) in particular his long term case manager [name] have not been shown to the above mentioned people.
In every single report the IME’s reports clearly indicates that my son has no capability to under take any sort of return to work assessment,both at present and future and would seriously effect his already unstable mental health.He has tried to take he’s own life on numerous occasions.
A recent questionnaire was sent to his treating GP with out the IME reports being forwarded for his viewing and making a proper assessment and future treatment which the IME have clearly stated that he be reviewed in twelve Months time and further more my sons treatment to be closely monitored due to no improvement in he’s mental state of mind.
Mrs [Allianz Case Manager] was asked in a recent letter which was written by [my son] and helped by me [name] his mother on why the reports were not sent to his doctor for referral before the questionnaire was filled out.
She did not respond to why this had not been done only to write another letter stating that she believes that my son has a capacity to return to work on the return to work questionnaire.
She is not a Doctor nor a life manager
Dr clearly stated on my sons recent visit on the [date] that my case manager did not phone or write to him as asked of her and explain why his reports were not sent to him by the case manager before making a decision on the questionnaire of which was answered without viewing the psychiatric report.
This is clearly a mishandled attempt by his case manager to further hinder my sons mental healing process/harassed to a point he needs supervision so he does not try to commit suicide.
Dr [A] did in fact state my sons mental/Psychiatric state should be evaluated by a medical panel which is up coming which in turn will determine his current and future prognosis.Mrs [Alianz case manager] knows of this as well, but has clearly demonstrated to hold back valid psychiatric reports to my sons treating Doctor of treatment/valuations for the purpose of denying my sons rights of a fair and legal medical based assessment governed and passed through work cover legislation.We urge you to review this as other health care advocates within the Victorian state,and federal MP’s have also received this letter for investigation.
We strongly believe this is harassment and call for a full investigation.As we were told by legal advises that this is not the first time Allianz Work cover agents have been involved in with holding information from both patient and treating doctors.
Xchanging hides crucial evidence from IME
I was recently sent (yet again) to an independent medical examination for an “objective” (excuse me!) assessment of my physical injury. The IME showed me a list of the material workcover had sent him and guess what? They only submitted a very old report from my treating surgeon dated 2006 and, unbelievably, a copy of a report from my treating psychiatrist!!!
How on earth is this IME supposed to provide an “objective” assessment of a complex orthopedic injury, without a copy of all surgical reports, no MRI or x-ray results, no recent reports or letters from my treating specialist who between brackets requested approval for very major surgery just a few weeks ago, no bone scan test results, just nothing!
Are they really stupid or what! Do they honestly think that (most) IME’s can’t see through their little schemes? It’s absolutely disgusting to what length workcover agents go to cover up your injuries or the extent of your injuries.
The value of a workcover claim is based upon the medical evidence the major part of which consists of the medical report supplied by an ‘independent’ medical assessor who just happens to have been paid for by the insurers who will be responsible for settling your claim and for paying out any financial compensation. It is worth remembering that an insurance company is a commercial business whose first responsibility is to shareholders, who expect to receive profits shared out by way of dividend every year.
The insurers are not doing you any favours and you are not high on their list of priorities when they consider the content of your claim form and genuine medical reports from your own treaters who know you best.
In almost every case it is recommended that you obtain your own medical evidence from an ‘independent’ medical consultant of your choice and/or that you always ensure that you provide your own copies of all medical related reports/letters/results to the IME, the Medical Panel, rehab service provider etc.
Has your workcover case manager deliberately withheld crucial medical evidence to your rebab service provider, IME, Home Help assessor, Medical Panel, etc… Please share your story and help us expose the real dirty tactics so commonly used by workcover insurers!
Yesterday, aworkcovervictimsdiary received an email from an injured worker who has been repeatedly denied basic home help by Xchanging, leaving her marooned and facing a very cold winter…The injured worker is also seeking assistance to navigate this dreadful Workcover system.
Xchanging denies basic home help to injured worker – a story
I am an injured worker and my file is currently managed by Xchanging.
My treating GP has made requests to the insurer for assistance with home help and garden upkeep.
This is slowly happening but not at the level I require, of course. After two ADL’s this year, we are now in debate about the possible recommendations an upcoming report ‘Workable’ can produce for the Insurer.
So far, by emails with Workable, I am being advised that although my adult daughter does not live at home and she works and lives 65kilometers away, the Insurer expects she is to assist me with one of the garden chores I have requested assistance with when she visits me.
She has already spent too many years helping me out, it’s time for her to get on with her own life and be happy. Her not being at home honour bound to help me is a much healthier and normal life for a 23 year old.
Also, another request my GP has made is assistance with Wood Deliveries as my Primary Source of Heating is a Combustion Heater in the Lounge room.
Wood collecting was another chore my daughter assisted with. I have been advised by Workable that this assistance is unlikely to occur because I am unlucky enough to have a small gas heater in the Dining Room.
I am expected to use this to keep warm through Winter although this heater barely provides enough heat to warm the room it is in due to the small size of the heater (it’s not a wall furnace) and open plan design. It is also meant to be only a supplementary heating source to the Combustion Heater. Historically we have always used Wood and the Combustion Heater for heating but this is of no consequence in this instance.
At this stage of discussions, it would appear that Xchanging expect me to spend Winter bunkered down in the Dining Room to try to keep warm rather than use my Loungeroom, my key living area, as I would normally do in winter.
I have pointed out to both parties I am rather glad the Workable Assessor didn’t notice the ceiling heater in the Bathroom as I get bad visuals at the prospect of spending winter in there to keep warm as an alternative. I am awaiting a reply on this matter.
There are other issues pertaining to the assistance requests but they are too lengthy to put in this message but I am happy to provide them to someone who is able to assist me to navigate this dreadful Workcover system. Any help would be appreciated.
Unfortunately this an all too common scenario. The way WorkSafe (and basically all workcover authorities) and, in particular, the way the workcover insurers interpret the act (legislation) is set up in such a way that any excuse will be used not to grant you household help in terms of “labour”. Workcover and their agents will indeed use your family members and expect it reasonable that your own spouse, kids, mother, grandfather etc. will take care of you and of the household tasks.
Also, one must remember that so called “rehab service providers” and, in particular OT’s, are in fact chosen because they “will not cut off the hand that feeds them”. What this means is that the “independent” assessments and reports you undertake an receive from OT’s (i.e. home help assessment) will be extremely biased and will heavily focus on “keeping you independent”.
We have been told that many initial OT assessments will be “corrected” (fiddled with) by the workcover insurer (i.e. case manager) as to come to a “favourable agreement”.
In June 2011 Lisa’s own medical treaters requested urgent home help for her, based on the fact that she has lost all function in her dominant arm. She underwent 7 major surgeries and is now in need of a reverse shoulder prosthesis.
The OT’s initial assessment recommended that Lisa NOT be provided with manual home help, and instead recommended things like a long handled toilet brush (WTF), a suction brush to stick on the sink so she can was dishes left handed (WTF), a steam mop which she is unable to even ready (i.e fill water canister, add mop to the device) or maneuver and a long handled bathroom tile scrubber (of which the picture as reported in the assessment report, shows a lady using 2 hands to use it!).
Now, Lisa is not even able to get dressed on her own, to shower unassisted, to cook (at all) and even to eat meals without assistance. They[Xchanging] even provided her with a fork and knife in one (as special utensil for disabled people so they can eat with one utensil) and a plate guard so she does not spill her food (off her plate) whilst eating.
In December 2011, Lisa underwent an arthroscopy and some major debridement of her right shoulder, however, she suffered very severe heart failure during the anaesthetic. An urgent request was made to Xchanging to review their initial decision to deny home help, but guess what, home help was DENIED again!
So here we have a severely injured worker (in need of a shoulder prosthesis)a and in severe heart failure, yet Xchanging deems it “inappropriate” for Lisa to have home help (and taxi travel)!
Snippet from the OT home help assessment:
Rejection letter Xchanging
Subsequently, Lisa – in a desperate situation – had no option but to appeal Xchanging’s most unreasonable decision to still deny her basic home help at [popup url= ‘http://www.conciliation.vic.gov.au/ ‘]Conciliation[/popup]. Lisa’s lawyers had also advised her that if she would not be successful at ACCS, the matter would be fought all the way in a court of law!
In March 2012 (almost 1 year since urgent home help was requested) Lisa was able to dispute the matter at conciliation and with the assistance of [popup url= ‘ http://www.workcoverassist.vic.gov.au/wps/wcm/connect/wsinternet/Workcover+Assist/Home/’] WorkCover Assist[/popup], won 2 hours per fortnight of home help (as in cleaning services).
Lisa and her team wanted a more reasonable 2 hours per week, however Xchanging refused, and as such the Conciliator has forwarded the matter (the question for 2 hours per week rather than per fortnight) to the Medical Panel. Lisa is currently waiting for her appointment with the Panel.
In the meantime Lisa is receiving 2 hours per fortnight home help. However, it took Xchanging no less that 54 days after Conciliation, to get the “paperwork” straight (they breached ACCS ruling) and over 60 days to organise the first cleaning service, which Lisa only just received this week!
So all in all it took Lisa almost a full year to obtain basic household help – not at the level required- after an urgent medical request was made.
To say that our workcover system is sick is an understatement. It enrages us to hear and read such a stories, especially during at time where the need for “slashing of workers compensation benefits” is plastered all over the media. Fact is injured workers do NOT get their legally entitled “benefits”.
The workcover insurance companies are a for-profit business and all and any”benefits” are routinely denied, even to those severely injured workers who are in desperate need. They are trained in the art of bullying, intimidation and denial and will make all injured workers fight for their meager “entitlements”.
Look at it this way: in Lisa’s case Xchanging happily forked out at least $7500 ($5000 medical panel, $2500 ACCS including medical reports and assessments) to DENY her the much needed and basic home help she requires. Now tell me, how many hours of cleaning service could $7500 pay for?
But it is injured workers’ fault that the workers compensation schemes are in deficit?! In what world do we live in?
Workers are entitled to be compensated for the reasonable costs of personal and household services incurred because of the work injury and sets out how WorkSafe determines the type of services it will accept for payment (The Act ref S5).
Household help refers to the provision of services for basic and routine common housework and gardening tasks that the worker performed pre-injury and are essential for maintaining the worker in the home.
Services should be provided to help the worker’s recovery, rehabilitation and return to work and should be appropriate to the workers injury, stage of recovery, including their physical rehabilitation program and household circumstances.
Household help assistance is also supported by authorised occupational therapy services, provided by an OT in order to maximise a worker’s independence with household help activities.
The legislation also specifies that these services must be provided by a person who is approved by WorkSafe.
The following section outlines the requirements of the legislation and WorkSafe’s policy regarding compensation for household help.
Provision of services
What WorkSafe will consider paying for
Criteria for approving household help
Household help should only be approved where the:
worker has a clear entitlement·
requested service is a household help service
request is medically endorsed
cost of the service is reasonable and necessary in the circumstances
reasonable contribution of family/household members has been considered
service is provided by an approved household help provider.
The worker has a clear entitlement
The agent must ensure that the request is related to the worker’s work injury.
A referral is required from the worker’s treating medical practitioner. The treating medical practitioner must provide supporting evidence of:
the nature of injury, severity of injury and any functional limitations·
the relationship of the work injury to the ability to perform the requested services
the functional limitations arising from the injury
the anticipated duration of functional limitations
any pre-existing or impacting medical conditions or household circumstances.
The cost of the service is reasonable and necessary in the circumstances
The agent must assess the worker’s individual circumstances to determine whether the:
cost of the service is reasonable
service is necessary given the worker’s circumstances.
Agents should consider the following when assessing whether a service is necessary:
the relationship of the injury to the requested services
whether the service is for the worker
whether the worker undertook the tasks pre-injury
the worker’s ability to undertake the tasks post injury
the size of the worker’s home/garden at the time of the injury
the worker’s family circumstances
the contribution of family/household members.
OT to maximise worker’s independence
OT services should be used to maximise the worker’s independence using:
adaptive techniques or equipment
changes to work methods. For example: self-pacing tasks throughout the day.
These should be implemented before the use of labour hire service provision.
The reasonable contribution of family/household must be considered
WorkSafe expects that household members will assist with the running and maintenance of the household. Consideration must be given to the reasonable contribution of all household members in:
completing household tasks
assisting the worker to complete tasks.
When assessing contribution from family/household members their ability and maturity to complete tasks without risk to their health or safety must be considered.
Providers must be approved by WorkSafe
WorkSafe will only pay the reasonable costs of services where the service provider is approved by WorkSafe prior to the service commencing.To be eligible for approval, service providers must provide WorkSafe with evidence of:
Australian company or Victorian business registration
hold current public liability insurance cover ($2 million minimum).
Household services must be provided in a professional manner, so that the interests of all parties are protected.
Who can’t provide services
Personal and household services provided by a friend or family member are not an approved service and cannot be paid.
WorkSafe can refuse to register providers
WorkSafe may refuse to approve and register a provider if the provider or service does not meet WorkSafe requirements.
Household help services only extend to replacing a worker’s labour in the home for routine, common, basic housework or gardening tasks associated with maintaining themselves in the home and do not extend to other adult family members.
Services may extend to other household members
Household help can provide housework assistance for a household member other then the injured worker if all the following criteria are met.the household member:
lives in the home
is dependent on the worker to perform the tasks
is unable to perform the tasks themselves
there are no other adults living in the home to undertake the tasks.
provision of firewood
What WorkSafe will not pay for
WorkSafe will not pay for:
the cost of cleaning materials
standard housework or household appliances
self care tasks including bathing, dressing or personal grooming
support of hobbies or personal lifestyle interests. For example: hobby farm, animal breeding or showing
home or furniture maintenance including window washing, cleaning or drapes blinds or carpets
home modifications including painting, renovation or modification
property maintenance or repair including painting, watering gardens, gutter cleaning or maintaining paving
the cost of garden implements unless recommended by an OT as modification or assistive equipment for the worker
raw materials. For example: plants or mulch
fees for rubbish or grass removal.
What the worker needs to provide to the provider/agent
For WorkSafe to pay for household help services a worker must be able to show that the service is:
referred by the worker’s treating medical practitioner and medically endorsed
required as a direct result of a compensable work related injury
reasonable and necessary
unable to be completed by a family or household member
provided by an approved provider.
Workers can use the provider of their choice; however WorkSafe will only pay the reasonable costs of services when the:
service has been authorised prior to delivery
provider has been approved by WorkSafe to provide household help services.
To find out if a chosen provider is approved and has a WorkSafe provider number, the worker should ask the provider or contact the agent.
Failure to participate in a household help (OT) assessment or recommended OT services
Agents will request a household help (OT) assessment to obtain further information to determine the reasonableness of a request. If a worker does not participate in the assessment, or in OT services recommended as a result of the assessment the agent may use other available information to assess the reasonableness of services.
Household help service providers must be approved by WorkSafe prior to service provision commencing. To be eligible for approval, service providers are required to provide WorkSafe with evidence of:
Australian company or Victorian business registration
a current public liability insurance cover ($2 million minimum).
Household help services must be provided in a professional manner, so that the interests of all parties are protected.
All household help service provision must be for a specific time period authorised by the worker’s agent in writing prior to the delivery of service.Service authorisations will include the:
tasks to be provided
frequency of the service
dates the service is to be provided
service cease date.
What should be included on an invoice?
To help prompt payment of accounts, the following information should be included on an invoice:
OT / household help provider’s details including name, WorkSafe provider number and ABN
invoice number and/or date of invoice
worker’s name, claim number and date of injury (where claim number is unknown the worker’s date of birth should be provided)
date of service(s),item code, description of each service, fee charged for service.
Payment will only be made for services that have been authorised
Payment will not be made for services that:
have not been authorised by the agent
exceed tasks, frequency or dates that have been authorised.
Provider and worker notified if payment will not be made
If services are provided that have not been authorised, the provider and worker will be advised that payment will not be made for those services. The service provider will also be notified that:
future approval for provision of services may be jeopardised
the matter may be referred to WorkSafe.
Household help (OT) assessment report format
A household help (OT) assessment is WorkSafe’s customised household help assessment tool for use by OTs to assess a worker’s functional capacity in regard to household help activities.The assessment tool provides guidance to OTs regarding WorkSafe’s reporting and assessment expectations in regards to maximising a worker’s independence with household tasks.
What needs to be included in a household help (OT) assessment report
When writing the report, an OT must:
relate recommendations and the report to the specific scope of the assessment request
complete all relevant sections of the report. Where a section is not relevant, mark it as “not applicable”
ensure final reports are typed, of high quality and error free
be signed and dated by the OT who completed the assessment.
The report must be submitted to the agent within 18 working days of the request.
Note: If a report does not meet the requirements set out in the Guidance Material it may be returned to the OT for amendment at the therapist’s cost.
Payment rates and fees
OTs can charge a maximum of five hours for undertaking a household help (OT) assessment. The five hours includes:· liaison with the agent, worker and their treating health provider
conducting the assessment
education (where appropriate)
Additional reimbursement for travel may be granted in exceptional circumstances. The OT should discuss these circumstances with the authorised agent and seek approval prior to undertaking the assessment.
Note: Household help (OT) assessments are not an approved OR service or part thereof.
Payment only made for services provided
It is WorkSafe’s policy that payment will only be made for services that are provided. If the worker fails to attend or cancels an assessment, payment will not be made unless the agent is satisfied exceptional circumstances exist. For example: If the worker repeatedly cancels appointments the agent may exercise discretion to meet some of the OT’s costs.
If the request is received directly from the worker the agent must advise the worker within 14 calendar days that:
the request cannot be considered without a written referral from their treating medical practitioner
the treating medical practitioner will be asked to provide additional information regarding their injury and the relationship to the requested services
where service provision has or is likely to extend beyond 12 weeks, a household help (OT) assessment must be obtained to identify strategies to assist the worker to be independent in household tasks.
Request received from treating practitioner
If the request is received from the treating medical practitioner the agent must review the information provided to ensure that it is sufficient to make a decision to triage to a short term or long term strategy.If sufficient information is not provided, the agent must contact the treating medical practitioner for the relevant information. See standard letters:
Letter to worker- request for further information on a household help service request
Letter to treating practitioner requesting further information.
Within 14 calendar daysof receipt of the request agents must:
assess requirement and reasonableness of household help tasks requested as recorded by agent in task lists.
Speaking of rude and inappropriate case managers, some who deliberately delay or deny vital care to seriously injured workers, workcovervictimsdiary.com received some jaw-dropping evidence of the mismanagement – to the point of frankly-endangering the injured worker’s life, of an injured worker’s claim.
Xchanging Case Manager inappropriate claim management
A seriously injured worker, who’s last shoulder reconstruction ‘fell apart’ following grafts, and suffered extremely painful “posterior-inferior dislocation” (joint dislocating backwards and downwards) was referred by her treating upper limb surgeon for an MRI of the shoulder (to be done ASAP) prior to undertaking further reconstructive surgery.
The injured worker contacted the Imaging Facility to make a booking and was told that they would not accept workcover bookings without pre-approval for the MRI by workcover, in this case Xchanging.
The injured worker immediately contacted her case manager at Xchanging and asked for a 2-sentence letter of approval for the MRI for the Imaging facility do that she could have her MRI done as soon as possible.
The injured worker’s treating GP had also sent a Fax to the case manager to ask that the MRI approval (letter) be fast tracked as the injured worker was in great pain.
Email injured worker to case manager (1st email)
The MRI for the shoulder was prescribed by the injured worker’s upper limb specialist shoulder surgeon, and followed up as “urgent” by her treating GP, as well explained in the injured worker’s above email to her case manager.
Also, as is evidenced by this email, the case manager clearly harassed the injured worker about undertaking “work” or “volunteer work”, notwithstanding her serious physical condition – how SICK!
Request MRI from upper limb specialist surgeon
Faxed letter from treating GP to case manager (Susan Doran)
Email injured worker to case manager ( 8 days later)
Note the content of this email, the injured worker clearly states that she is “in excruciating pain” and “as such the MRI was to be promptly approved as per GP Fax!
The injured worker did get a reply (for once), and note that the case manager states that the “medical advisor has not completed the response” WTF?
Now, now, what on earth is this case manager doing, but deliberately obstructing urgent medical care of a genuinely injured worker?
We also note that the injured worker describes her [extreme] concern about her progressive loss of sensation- which is, indeed a potentially very grave condition [i.e. nerve damage, blood supply issue etc].
Extract of WorkSafe’s policy regarding MRI’s
Is prior approval required for an MRI service? An injured worker may be referred for an MRI service by a consultant physician or specialist recognised for this purpose by the Commonwealth Health Insurance Act (1973). In these cases prior approval from a WorkSafe Agent is not required. It is recommended that the referring consultant physician or specialist contact the WorkSafe Agent to confirm that their patient has an accepted claim and that the region to be scanned correlates with the region of the accepted injury.
Email injured worker to case manager one month later (!!!)
The injured worker clearly says here “she cannot go on like this any longer”…
Just over one full month after the urgent request was made for the MRI, the injured worker received “approval for the MRI” and, frankly, an extremely antagonising email from her case manager:
And the case manager also sent the approval letter to the doctor (WTF), where it is needed for the Imaging Facility (the injured worker needs it!)
As you can see from the case manager’s email, she states that “we do have 28 days to make a decision” and that “if the MRI was arranged through your treating surgeon you would not have had to seek prior approval and this would also have saved time...”
Now, now… what did the injured worker write in her very first email? Correct, that her surgeon (upper limb specialist surgeon) requested the MRI… and…correct, what did the GP fax to Ms Doran (the case manager) state? Right… that the MRI was prescribed by the surgeon… What does the MRI referral state?
We are speechless.
Following the MRI, it was found that injured worker had sustained further, significant damage to the shoulder (original injury) and that she needed further reconstructive surgery (7th surgery).
However, Ms SD was “not interested in the physical deterioration” of the injured worker!
Basically, the case manager fully ignored the injured worker’s certificates of physical incapacity, her acute deterioration of her shoulder condition and the fact that she needed urgent major surgery to her shoulder, and decided that she needed to be “re-assessed” by a highly biased IME psychiatrist to assess “whether she could engage in rehab and return to work… and of course to see whether they could cut off her psychological counseling as well… at a time she needed it most.
Perhaps we can sum up the honest findings of a truly independent surgeon’s opinion and that of a non-biased independent psychiatrist:
Surgical IME (around same time)
Psyhiatric IME (non biased)
Despite this injured worker’s serious physical condition, as well as her considerable mental injury, this case manager continued, at great length, to intimidate and harass this person, further inflicting unimaginable pain.
The injured worker tells us (and we have the evidence on file) that this case manager also forced her to attend a Vocational assessment whilst she was suicidal, and whilst she had in fact been unlawfully terminated by her employer because Xchanging had not provided the repeatedly requested ergonomic support in the workplace for “yonks”. During her last return to work, the requested ergonomics were still not put in place 4 months later and the injured worker was sacked based on “disability” from a desk job.
As we note from the IME reports, this injured worker is highly qualified and was in fact working in a senior management position prior to being sacked and would, indeed, not appear to need a “vocational” assessment and/or re-training. Jobs which were put forward to her by her case manager included working as a ward clerk…
Now, we can just imagine what this injured worker has been through…
The injured worker also tells us that her last shoulder surgery to her shoulder was delayed by over 2 months and that she had to write a letter of complaint to WorkSafe in order to get approval!
She also tells us, that in-spite of her serious physical disability and her recent severe heart complications sustained during her last shoulder surgery, she was repeatedly denied taxi travel and home help by Ms Doran, notwithstanding that 3 IME’s of this case managers’ own choice supported it.
The injured worker tells us she has become extremely depressed because the way she has been and is being treated by Xchanging, in addition to having to cope with her debilitating injury and its life-changing consequences, and cannot understand why anyone would want to treat a serious injured worker this way… Do you?
This case manager is also responsible for sending the rudest email we have ever seen to an injured worker!
–>To Miss SD: be grateful we censored your name in the bulk of the text for Google searches<–
workcovervictimsdiary.com just received a gut-wrenching email from a very aggrieved injured worker, alleging extreme bullying, harassment, intimidation and falsifying of material by Xchanging… This letter may cause significant distress to readers, discretion is advised. Please, please help us support this injured worker in any way possible.
Dear Sir / Magistrate
I have the matter listed for the [day] [month] 2012 at [time]. Can I request an afternoon time from 2pm onwards please in a month?
I currently have the flu and am unwell.
I need an adjournment for at least a month as I am still awaiting legal representation.
I am being harassed by xchanging and there lawyers, I have had the police from [location] Police station at my door [day] night[month] [day] interrogating me for over an hour and told me that they needed to see my mobile phone. They were intending to take me away and put into a psychiatric hospital, based on falsified unlawful allegations made by an xchanging team leader.
Once they spoke to my flatmate they realised I was not a risk to anyone. She contacted Melbourne [location] Police and spoke to a Constable and then sent [location] Police. I also received a follow up call from Psych department at the [location] .
A source from victims of workcover website contacted me saying I am one of many innocent victims and She (team leader at xchanging/workcover) has misused and manipulated the mental health act (to avoid paying out many injured workers) by this.
I left her a single voicemail message saying that I couldn’t be in chronic pain anymore and needed treatment via a payout. I am on a disability pension and have been ever since they cut my treatment off over 4 and half years ago. she is using the system, possibly unlawfully. She also has legal representation via very intimidating Lawyers who have also threatened me with costs. I do not know if they are aware of her manipulation of the act?
The team leader alleged to the police that I had left [x] hours of voicemail and left numerous text messages, which stated that I would self harm and harm her. This was a lie and there is no evidence to prove this unless she is falsifying material.
She has carried out similar actions on other innocent victims also in pain via bullying and harassment confirmed on a website.
The website containing similar reports from others like me http://workcovervictimsdiary.com/ There are a number of pages, listing other victims. I urge you to print and consider the information from this site.
I am concerned that this type of action is being carried out. I was very shaken and somewhat traumatised by this event.
[we have removed the name]
Dear injured worker – thank you for having the guts to share your letter to the Magistrate with us. We can only start to imagine what you are going through at this very moment. We are speechless.
May we urge you to contact Shine Lawyers – please contact John Typaldos (located on the right hand side in side bar) if you’re located in Victoria.
We believe we do know the Team Leader you mention, and a workcovervictim has herself been threatened by this person, including “police action” for having sent begging emails in “upper case” which never got answered. The injured worker had also emailed to her case manager that she was feeling suicidal by the way she was being treated by her case manager and that she did not understand why her “benefits” were being cut off without ANY reason, nor explanation… For that reason, that team leader sent the injured worker an extremely nasty and intimidating letter back, which also stated that Xchanging prohibited the injuredworker to make any contact with Xchanging (except via PO BOX) and that Xchanging would never answer any “previously raised matters” and would only reply to new matters via writing…All the injured worker did was plea and beg for a taxi trip, and an extremely urgent and important scan of her shoulder (site of injury) which were both denied without any explanation, leaving the injured worker completely marooned, sick, with a fever and in an absolute desperate situation. [FYI, both the scan and the taxi travel were ruled to be Xchanging’s liablity at a conciliation).
Please, please, folks, help us support this injured worker as best you can, mental support, friendship, encouragement, legal advice, anything, please!
We are happy for anyone of you to send us an email and we will personally forward it to the injured worker!
A few months ago, folks, an injured worker heard through his pharmacist that one of his prescribed (by his pain specialists!) pain medications was “under review”. His workcover case manager simply stopped paying for his medication without notice or explanation. About three months later, none of his treating doctors had received any inquiry about the medication and his pharmacist, understandably, refused to dispense his pain medication as Xchanging had not paid for the past three accounts…
My workcover case manager is “reviewing” my medication
WorkSafe must pay the reasonable costs of medication and other pharmacy items required as a result of a work-related injury or illness in accordance with s99 of the Accident Compensation Act 1985 (the Act).
You will note in the WorkSafe policies that WorkSafe states it can only pay for medications and pharmacy items requested by registered medical practitioners or registered dentists and which are provided by pharmacists that are registered:
with WorkSafe to provide pharmacy services
with the Pharmacy Board of Australia
To learn more about the requirements of the legislation and WorkSafe’s policy regarding pharmacy services, [popup url=’http://www1.worksafe.vic.gov.au/vwa/claimsmanual/Pharmacy.htm ‘] visit the online Claims Manual[/popup]
Note that the Online Claims Manual requires you to save “cookies” – they obviously like nothing more than to TRACK who’s visiting their manual! To find the relevant information about Pharmacy, go to the claims manual, then click on the left hand side “entitlement medical and like services” –>10.5 – A-Z of medical and like services–> Pharmacy.
Now, the injured worker tells us he had been prescribed a pain medication called “Topamax” in September 2011 by his treating pain specialist, who also happens to be the Director of a pain clinic of a very large public hospital in Melbourne – so, not just “anybody”, eh.
The Topamax was prescribed to him for severe neuropathic pain, aka nerve pain. Whilst Topamax is primarily used for epilepsy and migraine, it is also increasingly, and very successfully, used for treating neuropathic pain (i.e. Chong, MS; Libretto, SE (2003). “The rationale and use of topiramate for treating neuropathic pain”. The Clinical journal of pain19 (1): 59–68. ).
Pain specialist medical report extracts as sent to Xchanging case manager as from September 2011 to April 2012
Notwithstanding WorkSafe’s policy, the injured worker’s case manager did NOT inform him that his Topamax was being “reviewed” and what this meant.
The injured worker found out, through his Pharmacist, where he holds an account, that the medication had been under “review” for some weeks (1-2 months) already and that this means that Xchanging basically STOPS paying for it immediately.
So, when the injured workers went to fill his third Topamax 50 mg prescription, as issued by his treating pain specialist (who he sees every 3 months or so), his Pharmacist, regrettably, told him that he would no longer fill his prescription as Xchanging had NOT PAID for the two or three past Topamax accounts! The Parmacist agreed to give the injured worker 1 week’s worth of Topamax tablets and told him to contact “workcover” and “sort it out”.
The bewildered injured worker first contacted his treating pain specialist and his GP and inquired whether Xchanging had contacted then with regards to a “review” of Topamax. Both the pain specialist and the GP told the injured worker that no inquiry had ever been received from Xchanging regarding Topamax.
The injured worker then immediately contacted his case manager and asked him to immediately either settle the outstanding account with the Pharmacy either send the injured worker a rejection letter so that he could take the matter to Conciliation.
The injured worker received a reply about a week later, and he was told in writing that the Topamax had been approved (suddenly – no explanations given about the so called “review”) and that Xchanging’s case manager had contacted the Pharmacy to let them know.
Email received from Case Manager (via injured workers solicitor)
The injured worker also received an email from his employer confirming, a few days later, that Xchanging’s case manager had – finally – contacted the pharmacy and “sorted things out”…
BUT, when the injured worker attended the pharmacy to fill his Topamax script, the Pharmacist again told him that nobody from Xchanging had contacted him, and that, unfortunately, he could no longer fill the prescription.
The aggrieved injured worker emailed his case manager again and was told in rather ” unpleasant manner” that “the letter pf approval” had been sent the day or two days prior already via Express Post and that the injured worker could just take that letter to the pharmacist (who was to receive a copy as well).
The injured worker was basically left without Topamax, he ran out of the drug and had to stop the drug abruptly, which is highly contra-indicated!
Guess what, folks, some case managers are so thick they can’t even put the envelopes in the correct postal box. The “approval letter” was sent via normal post, but in an Express envelope. The Case manager had put it in the wrong postal box, as you can see on the envelope’s postal notice! And the injured worker gets “told off” for not having received the letter “in a timely manner”.
We are talking three months here for the Topamax “review”!
Approval letter (arrived in April2012 – “review commenced in Jan 2012)
So what is a medication review then?
In our seriously injured opinion, a medication”review” is nothing more than an attempt to cease ANY medication an injured worker is legitimately prescribed, in order to SAVE money.
Fact is, why did the injured worker’s own treating doctors such as his GP and, in particular his highly renowned pain specialist, not receive an inquiry into the “Topamax” and why it was prescribed for?
Fact is this medication had been prescribed by a specialist pain specialist, who also happens to be the Director of a pain clinic of one pf the largest public hospitals in Victoria.
Now, who is “reviewing” said medication? An uneducated case manager? An illiterate case manager? A workcover “doctors”? Unlicensed to practice real medicine? A workcover pharmacist who doesn’t know you from a bar of soap?Isn’t it enough to just read a few of the medical reports by the injured worker’s pain specialist to understand that there is a need for this medication (reason and rationale explained) and, most importantly, to see that the medication is genuinely beneficial and helps the prevention of opiate addiction as well? Wow…
Tell us, WHO is “reviewing” injured workers medications? And Why?
Tell us, WHY does it take over three months to “review” a simple drug?
Tell us, WHY is the injured worker not informed that their medication(s) is/are under “review”?
Fact is, many seriously injured workers are living in utter poverty. Having a pharmacy account in place and a pharmacists who is willing to put up with the crap from workcover agents is a god-sent. Having some dipstick “review” your medication for over three months, without informing you, and without even seeking information and or explanations from your treating prescriber is just plain criminal and is, in our seriously injured opinion, only yet another exercise in “cost reduction” and “profit making” for the insurer.
And it is people like Barry O’Farrell and Mr Baillieu who think it is funny to slash workers compensation “benefits” to seriously injured workers, or steal money from the WorkSafe “coffers”, when injured workers are not even capable of paying for their own pain medication and find themselves under ” medication review” and abruptly, and without any explanation, CUT off their much needed medication(s).
A medication review = cease of payment for the medication for no reason at all, but to save money. Don’t get fooled. get onto it. Ask your pharmacist whether there is “anything” under review. If there is, ask your treating doctors whether they have received any inquiries. Contact your case manager(s) immediately and remind them of the relevant legislation and policies (as per the claims manual; i.e: “Where further information is required, the case manager must request information within 10 working days from the relevant medical practitioner, pharmacy or injured worker. On receipt of further information, the case manager must review the information and make a decision within 10 working days). Demand they settle outstanding accounts or that they provide you with an immediate rejection letter so that you can appeal their “reviews” at the Conciliation.
Workcover and pharmacy medication: more information
Direct billing by a pharmacy
Injured workers may wish (and should) to approach a pharmacy about whether they are willing to send invoices directly to the agent (direct billing).
If the pharmacist agrees to direct bill the agent, the worker should provide the pharmacist with the following:
details of their claim number and name of their agent
the prescription for the items to be reimbursed by WorkSafe, and
if any non prescription over the counter items such as a bandage or splint are required for the treatment of their injury, a letter from the doctor or dentist confirming the requirement.
For WorkSafe to pay the pharmacy for an item purchased from there, a worker must be able to show that the item is:
required because of their accepted work-related injury or illness
provided on the request of a registered medical practitioner or a registered dentist, and
by a registered pharmacist.
Workers who request complementary and over the counter medications and pharmacy items must be able to provide a request from their medical practitioner that confirms the pharmacy item is for the treatment of their work-related injury or illness. It is good practice for pharmacists to take a copy of this letter and keep it on the worker’s file in case the agent requests proof that particular items are injury related.
WorkSafe recommends that pharmacists check with the agent or ask the worker for confirmation that the agent has accepted liability for vitamins and minerals before agreeing to bill the agent directly.
Reimbursement to worker
Injured workers can pay for pharmacy items themselves and seek reimbursement from the agent of the reasonable costs of those items by providing a fully itemised receipt as proof of purchase.
Where the pharmacy item is available on the Pharmaceutical Benefits Scheme (PBS), WorkSafe will reimburse at the PBS rate, not at the private medication rate. If the pharmacy item is only listed as private medication and not available on the PBS, WorkSafe will reimburse the worker at the private medication rate if the costs of the medication are reasonable.
WorkSafe will pay for the reasonable costs of medications and pharmacy items that meet all of the following criteria:
WorkSafe will not pay for medications and pharmacy items that:
do not relate to a work-related injury or illness
are not provided at the request of a registered medical practitioner or registered dentist
are not provided by a registered pharmacist
are not provided at a reasonable costs
are prescribed as part of a clinical trial
were required prior to the work-related injury or illness
are not invoiced according to WorkSafe minimum invoicing requirements
are not registered on the ARTG (except glucosamine).
Process for assessing pharmacy requests and invoices
[popup url =’http://www1.worksafe.vic.gov.au/vwa/claimsmanual/Process%20for%20assessing%20pharmacy%20requests%20and%20invoices.htm ‘ ]Process for assessing pharmacy requests and invoices[/popup]
Agent receives request
All pharmacy requests must have a medical practitioner request.
An agent can receive a pharmacy request via a:
re-worked pharmacy account that triggers a liability review
medical practitioner or injured worker.
To be eligible to receive payment of the reasonable costs of pharmacy items, a worker must be able to show that the item is:
required because of their accepted work-related injury or illness
provided on the request of a registered medical practitioner or a registered dentist, and
provided by a registered pharmacist.
Agent reviews request
The agent must review the relevant medical information on the worker’s claim file, including Novus and ACCtion. The review should include:
medical referral for the pharmacy items
recent medical certificates
previous pharmacy decisions for approved or rejected items
senior IMA or pharmacy team reviews
MA or Clinical Panel pharmacist recommendations
recent THP or IME reports.
Further information required
Where further information is required, the case manager must request information within 10 working days from the relevant medical practitioner, pharmacy or injured worker. On receipt of further information, the case manager must review the information and make a decision within 10 working days. Standard letters are available and are relevant to particular drug groups.
Following our popular article of yesterday about “things that annoy the sh*t out of workcover case managers“, a severely injured worker contacted us and shared a horrifying letter that was sent to her, after she had virtually begged herself stupid for medical help and support… After being repeatedly denied a legitimate entitlement, and without notice, the case manager had left the injured worker absolutely marooned whilst pretty seriously ill and potentially suffering from a life-threatening surgical complication. That the injured worker, at the end of her tether, and bewildered, had used upper case letters in an email and had allegedly used “foul language” was consequently held against her! They even threatened her with POLICE action, WTF!
Xchanging: police may be called upon receipt of a threat via email, phone or mail – a threat includes writing in upper case letters
The severely injured worker tells us her treating doctors had requested urgent taxi travel and home help quite a few months prior to the start of these hellish “communications” with her “horrible case manager”. She tells us she had had major surgery and the surgery had not held. Within a few months of the surgery, things broke down and her surgeon suspected she may be suffering from a life threatening infection. She was also suffering from very severe depression and PTSD for which he was in treatment, paid by Xchanging.
Following the medical request for taxi travel, Xchanging’s case manager initially sent the injured worker to three IME’s for an assessment to see whether she really “needed” taxi travel to and from medical appointments. All IME’s strongly supported this. In fact they all wrote that he was to have indefinite supportive care and that the best and safest way for him to travel was by taxi, or being driven by a person. She was not fit to take public transport in her condition and “driving would be dangerous”.
Following the above medical evidence, and in particular the 3 Independent medical examiner’s support, Xchanging initially allowed her to travel and paid for about 5 taxi trips. Then, without notice, and without explanation, they left her completely stranded on the evening before he was to travel to a very important special scan (Gallium scan) to see whether she had an infection in the surgical area (joint).
Xchanging did not return her emails and gave no explanation except for one email stating that “they were waiting for further medical information before making a decision re taxi travel”. Needless to say that the injured worker was astounded, given all the medical evidence on file, including the 3 recent independent medical reports.
The injured worker felt extremely frustrated and desperate. She was very ill and running a fever at the time, and needed to get to that important scan and yet his case manager refused to let her travel by taxi, notwithstanding that her treaters and the IME all supported (and asked for) taxi travel. She then also found out that the case manager had denied her the scan!
Given that the injured worker has medical training, she put together her case and reminded the case manager of the IMEs, her injury, and – indeed- the consequences to her (and her case manager indeed) if she could not attend the scan and was found to suffer from that life threatening infection in the surgical area (+spread in bloodstream).
She received no answer to her emails and was getting really really desperate. She did not understand the reason why her case manager had suddenly cut off her taxi travel and now also denied her that scan. She understandably emailed her case manager in a more and more desperate manner, fueled by her desperate state, frustration and real fear of not being able to get the tests and treatment(s) she so much needed.
After a multitude of PLEASE PLEASE emails, she eventually wrote to her case manager that if she would not provide her with the requested and legitimate travel request, she would – regrettably – lodge a formal complaint with WorkSafe, Conciliation and the Ombudsman.
She also gave the case manager a written deadline to get back to her with a clear and valid explanation as to why his travel request, scans (and home help) were suddenly being denied to her. Again, she did not get a reply, and found herself completely helpless, hopeless and totally marooned. She was unable to attend the special scan, she was ill with fever and worried sick. Totally desperate and left in the gutter.
The injured worker never spoke with her case manager via telephone, as there were already intervention orders in place, which were supposed to prohibit the case manager from contacting her directly via email and telephone. All correspondence was to be in writing and opened by his treating psychologist or psychiatrist, who she was seeing for severe secondary depression with suicidal ideation and PTSD, of which some had -in fact- been documented as being caused by bullying ad harassment on the part of Xchanging and in particular her case manager! The case manager, however, had no respect for the orders and in fact breached the orders right up until the day she was eventually, successfully replaced (via her lawyers).
Letter from Xchanging
click to enlarge a bit
But WOW, WOW, WOW! Hallelujah!
Xchanging employees are provided training in the handling of abusive and threatening telephone calls. Please be advised that phone calls may be terminated… In accordance with Xchanging’s policy/training/protocol, POLICE may also be contacted upon receipt of a threat made via email, telephone or mail against any of its employees!
As you can see from Xchanging’s letter, they have used the injured worker’s desperation against her, and actually accuse her of abuse, threats and wrongdoing! What a f*cking joke!!
The injured worker says she rang her case manager’s manager (aka Team Leader) the night prior to the travel to the special scan to see what the problem was and why she was being denied taxi travel (and the scan), and why her case manager was not responding to a multitude of emails sent in desperation for answers.
The Team Leader accused the injured worker of “lying”, when the injured worker stated that taxis had already been provided to prior trips (x 5) and that she did not understand why she was suddenly denied the next trip as well as the scan to seek a life threatening infection.
Proof that Xchanging lied
When the team leader accused the injured worker of lying and also stated that the injured worker was “fabricating” said “support from doctors and IMEs for taxi travel” *WTF*, she went ape. Of course she went ape and she tells us she yelled on the phone and, yes, she “threatened” the Xchanging team leader with legal action for endangering a person’s live and for deliberately obstructing care and legitimate entitlements. She also “threatened” the team leader with taking the matter to “WorkSafe”, the Ombudsman, the media and her local MP!
The case manager was definitely under the mis-understanding (what a kind word) that the scan was for a finger – and not for the injured shoulder, says the injured worker, although her surgeon had already spoken to the case manager and even emailed! I mean can’t case managers even read a prescribed test or what?
Oh and by the way, the injured worker has a very severe injury to her right arm and is unable to physically type, so she normally uses dictation software to type emails. The email that was fully sent in “upper case” – allegedly “yelling” was no more than a technical issue with the voice recognition software. Ask anyone who uses this type of software and you will hear that it is not as straight forward as one thinks, especially not when you are in a hurry and, yes, angry, emotional or upset and not thinking straight.
Here is one such an email referred to in that letter:
How rude is that folks?
Another email: too rude or what? You be the judge
Here is the original “rudest” email they refer to in their letter:
And the injured worker tells us she had sent this last email, after about 9 emails went unanswered, and after she had emailed, very politely (as above) numerous time for an explanation on why the scan and taxi was denied to her without an explanation. The above emails are the last couple of ones as referred to as the “rude” ones – WTF!
In return for this, the injured worker received that *unsigned* (did you notice?) letter from Xchanging – wherein they clearly imply that the injured worker must have done God-knows-what to threaten her with “police action”, how sick! But how fully sick is this, folks!
But, check this out, guys, even the ACCS rules that Xchanging has the duty to provide this injured worker with taxi travel (and the scan, plus subsequent surgery etc)
As we showed in our post of yesterday, talking “shop” with your case manager will drive them insane – in this case, all the injured worker did was discuss the genuine issues surrounding the injury and genuine need for urgent care, and stand up for being denied a legitimated entitlement (focused here on taxi travel, supported by at least 7 doctors, of which 3 IME’s!)
Now, when injured workers get treated like parasistes and yelled at, when they get abused, coerced and intimidated, lied to and denied legitimate entitlements, they do not have the privilege of writing a rude letter, threatening or implying police action…. God ,no, if they even imply that they will make a formal complaint to WorkSafe, they will get a very, very nasty letter in return.
In what world do we live, folks?
What do YOU think of this?
Have you received or sent a “rude” email or letter to your case manager? Please share it with us!
Note: By the way, through our research and ever growing evidence database (thank you injured workers for sharing your stories and experiences) we have been able to identify this lovely case manager lady and we have also been able to link her already to the following cases: