Standard of Practice 33: Managing psychological injury claims
We are seeking feedback on a new psychological injury Standard of Practice. The new Standard aims to set expectations for insurers about the management of claims for workers with a psychological injury.
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The Issue
Consultation period: 28/09/2020 5:00 pm to 06/11/2020 5:00 pm
What is it about?
Consultation on new SIRA Standard of practice for insurers
We are now consulting on a new Standard of practice for managing psychological injury claims.
SIRA’s Standards of practice outline expectations for insurer claims administration and conduct.
The new Standard of practice will set expectations for insurers about the handling of claims for workers with a psychological injury. It is being designed to support insurers to adopt practices across four key evidence-based domains:
- Person-centred approach
- Collaboration
- Early identification of support needs
- Outcome focused decision-making
These domains are described in the Safe Work Australia publication Taking Action: A best practice framework for the management of psychological claims in the Australian workers’ compensation sector - PDF (3MB)
Next steps:
SIRA is seeking your feedback on the consultation draft Standard of practice by no later than 5pm, Friday 6 November 2020.
Comments and feedback on the new SIRA Standand of practice should be submitted online or via email to [email protected].
Any enquiries about the consultation process should be sent to [email protected].
Due to the impacts of the COVID-19 pandemic all feedback is to be submitted using our online form.
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Milestones
28 September 2020 - the New SIRA Standard of Practice Managing is open for public consultation
6 November 2020 - Public consultation process closes. All comments and submissions must be received by 5pm, Friday 6 November 2020.
17 February 2020 - the updated Standards of Practice and a table changes have been published.
Due to the impacts of the COVID-19 pandemic all feedback is to be submitted using our online form.
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Outcomes
Introduction
The State Insurance Regulatory Authority (SIRA) undertook public consultation on a new Standard of practice for managing psychological injury claims from 28 September to 6 November 2020.
The consultation draft of Standard of Practice 33: Managing psychological injury claims was developed using the evidence based guidance underpinning the Safe work Australia publication Taking Action: A best practice framework for the management of psychological claims in the Australian workers’ compensation sector1 (the Taking Action framework).
A specific Standard of Practice for psychological injury was developed for the following reasons:
- As reflected in the Taking Action framework, psychological injury claims often present unique challenges that are not seen with physical injuries
- There is an upward trend in number of claims for psychological injury and an increased cost2 of these claims
- To articulate clear and consistent expectations for insurers regarding claims handling for workers with a psychological injury.
SIRA engaged directly with stakeholders and received 21 written submissions of which 10 were confidential, as a result of the public consultation.
The following provides a high-level summary of the feedback received throughout the course of public consultation.
General
A proportion of feedback received was considered out of scope for a Standard of practice for managing psychological injury (the Standard) whose purpose is to provide direction to insurers for the handling and administration of claims under the workers compensation system. Where appropriate this information will be incorporated into supporting guidance information to support the Standard, with the intent of improving the way in which psychological claims are managed and the overall efficiency of the workers compensation system.
Principle
There was significant support for the Standard with most stakeholders favouring the intent of expectations which are evidenced based and tailored to optimise outcomes for psychological injury claims. A common theme was that the Standard should further articulate expectations for incorporating workers individual circumstances including the nature of their psychological injury into claims management practices.
There was general agreement for the claims handling principle that ‘Psychological injury claims are to be managed with empathy and a strong focus on early treatment, recovery and return to work, and in a manner likely to minimise conflict and delay’. Further, a commonly expressed view was that the wording should reflect ‘timely return to work and health’ where the standard states ‘return to work’.
Some stakeholders suggested it was unnecessary to create a specific standard for the management of psychological injury claims as there was no need to differentiate between different injury type claims. Furthermore, existing legislation, guidelines and Standards of practice adequately meet expectations.
Feedback incorporated:
The principle has been amended to include ‘tailored communication, timely recovery and return to work’.
33.1 Focus on early treatment and return to work
There was support for the focus on early treatment and return to work after injury notification.
A commonly expressed view was that there are occasions when it is not possible to consult with a worker for medical reasons, and in these instances, it may be appropriate to instead consult via the worker’s authorised representative.
Additional key themes emerged relating to experience of case managers, approach to early contact, strategies to tailor treatment, return to work and disclosure of injury.
Case manager experience
It was suggested that ‘appropriate experience’ be clearly defined.
Strategies to approach early contact, tailoring of treatment and return to work
A commonly expressed view was that a biopsychosocial approach should be adopted to tailor treatment and workplace supports to increase the likelihood of a successful return to health and work.
Some stakeholders expressed the view that the Standard be amended to better reflect practices that are designed to support employers and workers in relation to managing interpersonal workplace conflict. Stakeholders advised there is a need for greater engagement with the employer to be actively engaged in return to work including during the dispute resolution process.
Disclosure
One stakeholder suggested this expectation be removed as it may not apply to all cases and is covered in the preceding expectation. Other stakeholders raised concerns regarding potential unintended consequences related to disclosure if not managed sensitively.
Feedback incorporated:
The expectation for case manager experience has been further clarified so that the claim is allocated to a case manager who has the interpersonal capabilities and skills relevant to the workers individual needs.
Early contact, tailoring treatment and return to work is to be based on the workers individual circumstances and nature of the injury. The biopsychosocial approach has been incorporated into the expectation at S33.6.
Claims management practices relevant to engagement with employers has been strengthened throughout the Standard.
Disclosure of injury has been amended to reflect the worker’s preferred approach to disclosure.
33.2 Determining liability
The intent was supported however some feedback suggested the wording was ambiguous and could be interpreted to be contradictory to the reasonable excuse provisions of the Workers Compensation Guidelines.
There was support for reasonably necessary treatment to be provided to a worker when the insurer applies a reasonable excuse not to commence provisional weekly payments.
One stakeholder expressed the view it would be beneficial for insurers and workers to have a more structured, uniform and supportive process stipulated in the Standard around alternative supports when a claim is denied, or benefits cease.
Feedback recommended the Standard also requires the insurer to communicate any actions resulting from a decision, this may include enabling a worker to help follow up a required report. One stakeholder expressed the view that the nominated treating doctor be notified to ensure appropriate supports are in place.
Feedback incorporated:
Decision making regarding provisional weekly payments based on an unclear diagnosis or insufficient medical information has been amended to reflect that if the diagnosis on the certificate of capacity is unclear, the insurer is to make reasonable efforts (such as written and verbal attempts) to contact the doctor prior to making a decision.
Inclusion of requirement to have regard to Clause 41(5) of the Workers Compensation Regulation 2016 and ensure the approach taken is documented on the claim file if the insurer is of the opinion that supplying a worker with a copy of a report as an attachment to a decision notice, would post a serious threat to the life or health of the worker or any other person.
33.3 Effective communication and planning
The intent behind effective communication and planning was generally supported. One stakeholder requested reframing the expectation about identifying appropriate contacts in the workplace to provide further clarity surrounding matters relating to the workers confidentiality.
Additional key themes emerged from the feedback in relation to developing a collaborative and tailored communication plan for a worker and facilitating a workplace culture conducive to an optimal return to work outcome.
Communication plan
Feedback recommended removing any reference to a separate ‘communication plan’ in addition to the injury management plan and the Recover at Work plan with one stakeholder noting, the Injury Management Plan has legislative compliance requirements which an additional communication plan would not.
Workplace culture
There was a view expressed that an insurers ability to influence workplace culture conducive to a return to work, may be out of scope/control of the case manager with one stakeholder expressing the view it is not reasonable to be included as an expectation within the Standard.
Feedback incorporated:
Reference to a separate ‘communication plan’ removed. Wording amended to reflect that the injury management plan (with specific detail in the recover at work plan) should:
- outline a collaborative and tailored communication approach that sets clear expectations about the frequency, timing and purpose of contact between the insurer and the worker
- articulate for the worker, employer and treatment providers expectations about recovery and return to work, outlining an approach to manage potential return to work barriers and minimise conflicts or delays
- facilitate positive and constructive engagement between the worker and the employer to promote a workplace culture conducive to an optimal return to work outcome.
33.4 Treatment
There was support for this requirement. Feedback included suggestions to:
- revise the wording to ensure facilitation of work focused treatment in line with evidence-based research tailored to the worker
- include an expectation that an objective assessment of whether treatment is achieving expected outcomes will be undertaken
- advise the nominated treating doctor if treatment requests are declined as soon as practicable
- Independent Consultants be engaged in consultation with the worker and treatment provider if treatment is not ‘achieving outcomes’ rather than achieving ‘desired’ outcomes, and
- promote the engagement of a workplace rehabilitation provider at the earliest opportunity once the worker has capacity for work.
Feedback incorporated:
Inclusion of an expectation to support evidence-based treatment, focussed on return to safe work.
Amendment to include worker and treatment provider consultation occur before referral for a second opinion.
Removed the term ‘desired’.
33.5 Recovery at work support
There was support for this requirement. A commonly expressed view was that management of workplace disclosure and accessing existing workplace supports would be incorporated into the Recover at Work Plan, developed in collaboration between the worker, their employer and the nominated treating doctor.
Additional feedback included suggestions:
- to provide clarity regarding what is meant by ‘cognitive, interpersonal and intrapersonal factors’
- to include an expectation to ensure a return to a psychologically safe workplace as there is a need to address psychological risk to enable a worker’s safe return and successful recovery
- that Injury management plans should be reviewed by an appropriate medical professional prior to implementation or at very least, consultation take place with the workers treating providers when developing a plan that considers psychological capacity.
Feedback incorporated:
Examples of psychological capacity provided.
Clarification that the injury management plan explicitly deals with the nature and extent of any disclosure of injury agreed with the worker to enable support in the workplace from co-workers to inform return to work planning.
Inclusion of an expectation to ensure workplace psychological risks are identified and addressed to enable the workers return to a psychologically safe workplace to enable a successful recovery at work.
If the worker is unable to return to their pre-injury employer, the insurer is to promptly amend the recover to work goal and commence activities to obtain alternative employment.
33.6 Secondary psychological injury
Stakeholders expressed support for this expectation. Some insurers expressed the view they recognise and value the importance of adopting a biopsychosocial approach in identifying claims where there is an elevated risk of developing a secondary psychological injury and support an expectation which proposes the insurer act quickly to implement reasonably necessary treatment and support plans to assist the worker and employer.
Furthermore, a commonly expressed view was that high-risk claims be managed as potential psychological injuries from the start of a claim and that an evidence based biopsychosocial approach be adopted for accurate identification of workers with an elevated risk of developing a psychological injury.
One stakeholder expressed the view that the expectation to predict and identify a potential secondary psychological injury claim should not be included and another indicated insurers should not be obligated to guess at potential claims.
Feedback incorporated:
Amended wording to include insurers are to screen for biopsychosocial factors (biological, psychological and social factors) to identify claims where workers are at an elevated risk of developing a secondary psychological injury.
Wording amended to clarify that when an insurer identifies risks for secondary psychological injury, the insurer is to, where appropriate, develop a tailored strategy to facilitate support.
Revised Standard of Practice
Following public consultation SIRA has amended the Standards of practice: Expectation for insurer claims administration and conduct (Standards) to include a new Standard for the management of psychological injury claims (Standard 33) which will take effect from 1 March 2021.