It's quite common to hear about lengthy delays, Certificates being rejected and GPs who aren't SIRA compliant, but it's vital to understand how these systemic barriers impact on your ability to access the treatment you need.
The Growing Gap Between Injured Workers and Specialist Medical Care
It's becoming clear that injured workers in NSW are facing a difficult task, trying to get an appointment quickly with a doctor that understands the WorkCover and CTP claims process. This is becoming a huge barrier for injured workers across NSW and is caused by a variety of factors such as, complexity of paperwork and regulations, as well as many traditional medical practices refusing to deal with compensation claims.
The impact of the Shortage is clear and tangible: injured workers are having to wait weeks or months longer for the medical certification they need for a successful Workers Compensation claim. Non-SIRA compliant Medical Certificates are resulting in successful claims being refused, benefits suspended and huge administration for injured patients who are already coping with significant physical and financial hardship.
This represents a significant gap in the healthcare system that has resulted in a cohort of patients who require not only effective treatment but also documentation that is SIRA compliant, correct billing codes and clinicians with an understanding of the interface between occupational health and insurance. A general practice based on the Medicare model of a routine consultation is not well positioned to meet the needs of this group of patients. Injured workers are therefore not receiving the medical care to which they are entitled under their workers compensation claims.
SIRA Compliance Requirements That Leave Traditional Clinics Behind
All practitioners involved in providing medical treatment to workers compensation claimants in NSW must comply with State Insurance Regulatory Authority (SIRA) guidelines and the principles of the workers compensation scheme. In addition, the management of workers compensation claims falls within the jurisdiction of the workers compensation authorities. SIRA has replaced WorkCover and now provides regulation for medical treatment in relation to workers compensation, amongst other responsibilities. Claims are still handled by insurers who set fees for services provided, the assessment and decision of causality falls to the treating doctor, while assessment of the extent of injury falls to specialist practitioners. There are distinct fee schedules for common medical treatments that differ from those applicable to Medicare services and involve the use of modified MBS billing codes, specific medical request forms and differing documentation requirements that may not be acceptable to other health insurers. It is very different to the Medicare model of care and practice requirements need to be adjusted to meet these needs.
In accordance with SIRA, Medical Certificates must confirm work capacity, list functional capacity limitations, list any treatments required and the date these can commence, along with the date the person can return to work, all in medical terms and in a specific format. The standard high volume / short consultation General Practice clinic model, designed for optimal Medicare billing, does not provide enough time or appropriately skilled clinicians to undertake the task of creating the required medical certificate. A 10 minute Medicare consultation does not provide adequate time for a full assessment of a WorkCover claim and necessary documentation required for the certificate.
It is only when you have to actually do all the administrative work required to deal with an injured worker, that you begin to see just how complex this whole exercise really is. And I'm not just talking about forms, but right through to claim adjudication and liaison with the insurer, bills reconciliation and even ensuring compliance with all regulatory requirements. The complexity and lack of predictability of the remuneration (or lack thereof) paid to practices for looking after the care of WorkCover patients (ie. the injured worker) is well beyond what is easily managed for the average practice. As many will have discovered, trying to continue providing care in the circumstances that a WorkCover claim is involved – even where it appears initially straightforward – ultimately leads to the entire business becoming an unmanageable exercise in bureaucratic and financial futility. The effective closure by conventional general practices, because they cannot economically manage their participation in WorkCover schemes to provide for the care of their WorkCover injured patients, leaves workers with access to almost no relevant specialist medical provider who can effectively participate in a SIRA-managed claim process to deliver the care the claim is meant to be about.
Why General Practitioners Decline WorkCover and CTP Patients
It appears that GPs across Australia are refusing to accept WorkCover and CTP injuries. This is leading to considerable difficulty for injured workers in gaining access to care. Understanding why this access barrier has arisen is important. It's not unique to workers compensation. However it's clearly a “systemic” problem in the way a general practice business is run. While individual motives will vary depending on the practice and its owners, some common drivers may include:
The main impediment is the significant time cost imposed by WorkCover consultations. Medicare booked consultations are quick and efficient: they last 10-15 minutes at the most and they pay immediately. The WorkCover initial assessment has to be comprehensive, documentation and care plans have to be written, communications with insurers and employers have to be undertaken and all in a duration that is likely to be anywhere from 20-30 minutes or more. All this in addition to the administration and therefore a large opportunity cost in relation to productivity for high volume practices.
WorkCover charges, scheduling and administrative time all add to the already significant burden on GP practices. Billing WorkCover for surgeries charges the practice an approved fee, with the claim submitted to the relevant insurance company (similar to going to an ambulatory surgical centre, and billed through their insurer rather than to Medicare) and there are periods where the practice does not receive payment for surgery, which can be for weeks or even months in the case of a decline in claim from the insurance company. There is no reliability or speed in being reimbursed through WorkCover, as Medicare offers an almost seamless system of bulk billing and electronic payment on the day of the surgery. The GP has no real confidence that the documentation for surgery will be generated quickly enough, or in a form that the insurance company will be likely to pay, which adds yet another variable to the calculation.
In my opinion there is finally an insurmountable barrier to adequate competency. Occupational medicine as a discipline incorporates a vast amount of knowledge pertinent to compliance with work health and safety regulations, the procedures of insurance providers, effective return to work planning and a range of other issues outside the scope of routine clinical practice for GPs. Most GPs do not have WorkCover expertise. Regardless of their endeavour to learn about WorkCover, many will lack confidence and feel they are unlikely to effectively manage WorkCover claims. Given the substantial time and financial pressures on practices, along with the anticipated likelihood of a less than optimal management of a WorkCover claim it is easily understandable why many practices simply won't see injured workers with WorkCover claims. Thus we are left with a catastrophic access problem.
Geographic and Access Barriers in NSW's Workers' Compensation System
A map showing the distribution of WorkCover-experienced medical providers in NSW has highlighted inequities in access to care experienced by medical practitioners working under workers' compensation in NSW. While practitioners in the regions of Sydney and other metropolitan areas generally have some availability for WorkCover patients, workers in large parts of rural and regional NSW have much fewer choices and will often have to travel by car or plane for hours or even days in search of appropriate medical care, adding to the many difficulties faced by workers who are already coping with workplace injury. These additional inequities are an added burden to the many other issues present in the current WorkCover system and exacerbate the difficulties faced by workers who have been injured in the workplace.
The concentration of WorkCover accredited providers in metropolitan areas is a phenomenon also seen in the broader health care system. However workers' compensation medicine is a unique field of practice, and given the already heavy burden of general practice in regional areas, the expectation that GPs will attain the level of expertise required to sustain an understanding of the complex WorkCover system and its associated documentation demands is low. This means that SIRA compliant medical certificates and treatment plans are often in short supply for those injured in regional areas with many communities being currently unsupported by practitioners who can practise within the SIRA framework.
The transportation barriers are an added layer of the geographic challenge. Injured workers with mobility issues, those who do not drive, and those with acute pain or limited function due to injury are often severely impacted by having to travel long distances for appointments. Transportation issues that cause delays, cancellations and increased costs can all negatively impact timely medical care, the ability to adhere to treatment plans and the overall experience of care for the injured worker. For those living in rural or distant areas the geographic barrier can become a virtually insurmountable challenge, meaning that workers without existing access to care may be left without any practical way to access the medical treatment to which they are entitled under the workers' compensation system.
There are a plethora of further challenges inherent in considering the temporal element of access. Although there are many providers within metropolitan Local Government Areas (LGAs) that have direct involvement with WorkCover, it is not uncommon for booking to be available months, even weeks, in advance. Injured workers with urgent matters, such as certificate expiry and risk of being cut off, with little time to spare to attend the doctor, therefore may be forced to disregard any consideration of travel to the nearest clinic. In fact, as we will soon see, many challenges to access in NSW are multidimensional and are therefore not readily addressed by simplistic calls to injured workers to “travel to the nearest clinic” – the access challenges that are created in a highly concentrated workers' compensation system, and in which appointments for many clinics are well into the future, therefore present an enormous barrier to timely care being delivered within the workers' compensation scheme to injured workers in NSW.
How Telehealth-First Models Are Closing the WorkCover Doctor Shortage
Telehealth-first medical models could be an answer to the WorkCover doctor shortage. With the assistance of new digital platforms, it is possible to deliver health care services remotely, hence reducing geographical barriers and waiting time, and providing complex care through on purpose clinics for WorkCover and CTP. By structuring medical practices around the needs of WorkCover and CTP patients, rather than trying to fit complex needs into the general practice model, telehealth-first practices can address the underlying factors that have driven providers out of the workers compensation space.
Workplace Health and Safety Act 1995 (QLD) and associated WorkCover Queensland policy positions are more easily met through the structural advantages of telehealth. Safe video consulting can be used to undertake the detailed assessment and subsequent monitoring of an injury in the worker's home. Rather than being presented with the everyday challenges of navigating public transport or driving to and from healthcare providers and then dealing with being physically present for an assessment that can be done remotely, a worker is able to have a same-day appointment arranged – in the event of a worker's certificate being due for renewal and facing the prospect of having their WorkCover payments suspended due to a certificate not being provided on time – this is an often overlooked consequence to dealing with an injury when one is already under pressure to manage costs.
With telehealth clinics that focus solely on WorkCover and CTP claims, there is a much greater level of expertise in SIRA requirements, as well as an understanding of the occupational medicine principles and documentation required by the Insurers. In a MEDICARE focused clinic, WorkCover claims are often considered an occasional or secondary business. This means the business operations are still primarily centred on MEDICARE, as opposed to focusing solely on WorkCover and CTP. This allows our clinicians to have an in-depth knowledge of SIRA billing codes, certificates and treatment plans, as well as the communication processes required for insurer and employer engagement.
The economic model for a telehealth-first WorkCover clinic is designed to remove the significant economic barriers to providers being actively deterred from seeing workers' compensation patients. Without the overhead of expensive premises, a telehealth-first clinic can manage their workflows to efficiently document WorkCover information required by SIRA, provide lengthy consultations that take the time required to document all necessary information to satisfy SIRA, and charge patients without WorkCover claim numbers affordable fees, while still running a profitable business. With a valid claim number, patients are able to get their consultations bulk billed, with no out-of-pocket cost. The clinic still runs an efficient business based on digital workflows and the expertise to document all necessary information to achieve first acceptance of claim as required by SIRA. This provides an opportunity for an injured worker in NSW to have access to a specialist who is able to provide the required SIRA documentation to which the worker is entitled under their WorkCover entitlements.
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