Injury management consultant approval and regulatory framework

Part 1 About the injury management consultant role and SIRA approval process

1.1 Purpose

The Injury management consultant approval and regulatory framework (Framework) contains important information for health practitioners about the approval and regulatory framework that applies to an injury management consultant (IMC) in the NSW Workers Compensation System.

Part 1 of the Framework sets out information about the regulatory framework, processes and policies that apply to an IMC.

Part 2 of the Framework sets out the eligibility criteria, which are the minimum requirements for approval as an IMC with SIRA under section 45A(2) of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act).

Appendix 1 sets out the conditions of approval which an IMC must adhere to under section 45A(2) of the 1998 Act.

SIRA has established an approval and regulatory framework for IMCs to enable SIRA to:

• set and promote standards of competence in practice and quality of consultations and reports
• maintain an independent list of appropriately qualified practitioners who are well regarded by peers and demonstrate practice consistent with the high standards set under the approval framework and
• supervise IMCs to promote improved outcomes and experience for workers.

1.2 Information about, referral to, functions and requirements of injury management consultants

Referral to an injury management consultant

The insurer makes the referral to an IMC.

The insurer may refer to an IMC when a worker is identified at risk of delayed recovery or there is a specific return to work or injury management issue. Attempts to resolve the issues must have been made prior to initiation of a referral. Referral may be requested by the worker (or their representative), employer, nominated treating doctor (NTD) or other treating practitioner.

SIRA has established a number of Standards of Practice for insurer claims administration and conduct (Standards). Standard 14 of the Standards of practice provides information about the insurer’s obligations when making a referral to an IMC.

Functions of an injury management consultant

The Workers Compensation Guidelines sets out the functions of approved IMCs under s45A (4) of the 1998 Act including reporting requirements. An approved IMC must follow the functions set out in Part 6: Injury management consultants of the Workers compensation guidelines.

Fees and payments

SIRA can set the maximum fees for IMCs, under s339 of the 1998 Act for the provision of certain services, including the provision of a report for a claim for compensation or work injury damages. The maximum fees to be charged and paid are those set out in the Workplace Injury Management and Workers Compensation (injury management consultants fees) Order in force at the time of the consultation with the worker, the file review or discussions with stakeholders. This is available on the injury management consultants page on the SIRA website.

Conditions of approval

Under s45A (2) of the 1998 Act, SIRA can approve an IMC. That approval may be subject to conditions.

SIRA has imposed conditions of approval for an IMC that are minimum requirements which must be met by practitioners who have been approved to operate as an IMC. The conditions of approval are listed at Appendix 1 of this Injury management consultant approval and regulatory framework and will apply from the time approval is granted.

SIRA may, at its absolute discretion, revoke an approval, or refuse to approve a new approval if an IMC has not adhered to all the conditions of approval.

SIRA may amend the conditions of approval of an IMC from time to time. If SIRA amends conditions of approval during the period of approval of an IMC, SIRA will inform the IMC of the amendments. The IMC will be required to adhere to the amended conditions. The IMC may withdraw from the role at any time.

1.3 Approval process

• An applicant submits a signed application for approval, which provides evidence to demonstrate they meet the eligibility criteria
• SIRA will, at its discretion seek clarification or further information as necessary to confirm the applicant meets eligibility criteria. This may involve SIRA collecting information from the applicant, another person or body, including third parties and referees
• SIRA considers all information provided and determines the application at its complete discretion
• The applicant is advised of the outcome of the application in writing (including electronically)
• Applicants who are not successful are provided with a statement of reasons and advised of the available review process.

1.4 Period of approval

An IMC approved under s45A (1) of the 1998 Act will be approved by SIRA for a period of 3 years (with an option for SIRA to extend, at SIRA’s discretion), which will commence on a date specified by SIRA.

An IMC may cease their approval at any time during the term of the approval by notifying SIRA in writing.

1.5 Review process

A person who seeks approval as an IMC and is not approved can seek a review of the decision by submitting a written request to SIRA at [email protected]. The request for review must be made within 14 calendar days of the date the health practitioner receives notification by SIRA of the original decision. The request for review can include additional information in support of the application with specific reference to the criteria for approval that had not been met.

The review will be conducted by an independent officer who was not involved in the original decision. SIRA will undertake the internal review and notify the health practitioner of the outcome within 21 calendar days after receiving the request for review or after receiving the last document or information SIRA may request from the health practitioner.

1.6 Performance monitoring and quality assurance

SIRA may monitor the performance and compliance of IMCs in relation to the conditions of approval.

At SIRA’s request IMCs are required to provide information to SIRA for the purpose of monitoring their performance in the role and quality assurance.

SIRA may also monitor performance by reviewing complaints to SIRA and collecting information from another person or body, including third parties, to determine whether the IMC has adhered to all conditions of approval. This may involve SIRA analysing information including, but not limited to data, billing practices and service provision at any time.

At SIRA’s discretion, feedback on monitoring results may be made available to the IMC.

1.7 Complaints about an injury management consultant

Complaints about IMCs may be directed to:

• SIRA customer experience on 1300 656 919
• Health Care Complaints Commission (HCCC) on 1800 043 159
• Australian Health Practitioners Regulation Agency (AHPRA) on 1300 419 495.

SIRA may refer any matter directed to SIRA to an alternative regulatory body, with the consent of the complaining party.

If any party requires information about the complaints process, they may contact SIRA at [email protected].

1.8 Compliance with conditions of approval

If a complaint is made to SIRA about an alleged breach of the conditions of approval, or SIRA becomes aware of an alleged breach of conditions of approval, SIRA will review the information to determine whether a breach has occurred.

Before SIRA takes action in relation to alleged breaches of conditions of approval, SIRA will notify the IMC of the alleged breach through the contact details supplied to SIRA by the IMC and provide an opportunity for the IMC to respond. The action SIRA takes will depend on the level of risk the breach poses to individuals or the scheme.

SIRA’s regulatory response may include, but is not limited to education, monitoring, remedial action, reducing the period of approval of the IMC, suspending the approval of an IMC, revoking an approval or refusing to approve a new approval from that IMC.

SIRA may suspend approval and remove the name and details of the IMC from the public register and advise insurers not to make further referrals to an IMC while an alleged breach is being reviewed by SIRA or another regulatory body.

1.9 Revocation of approval

SIRA may revoke an IMC’s approval during their period of approval on the following grounds:

• no longer meets all eligibility criteria for approval as an IMC
• any breach of the conditions of approval as an IMC
• such other reason deemed appropriate.

SIRA will provide written notice (including electronically) to the IMC of the intention to revoke the approval with an explanation as to the reason for the revocation through the contact details supplied to SIRA by the IMC.

IMCs who have been provided with notice of SIRA’s intention to revoke their approval will have the opportunity to have this decision reviewed internally by SIRA in accordance with s53 of the Administrative Decisions Review Act 1997. The request for review must be made within 28 calendar days of the date the practitioner receives the notification by SIRA. The request can address SIRA’s reason(s) for revocation and include information on whether the reason(s) for revocation no longer exist.

Following internal review, an IMC may apply under s45A(6) of the 1998 Act to the NSW Civil and Administrative Decisions Tribunal for an administrative review of SIRA’s decision to revoke the consultant’s approval.

Part 2 Criteria for approval

SIRA will take into account the following criteria in reaching a decision about whether to approve a person as an IMC under s45A of the Workplace Injury Management and Workers Compensation Act 1998.

2.1 Eligibility criteria

To be eligible to be approved as an IMC, an applicant must:

• hold current General or Specialist registration with the Australian Health Practitioner Regulation Agency (AHPRA), with no conditions, undertakings, reprimands, limitations or restrictions on registration as a result of a disciplinary process. The practitioner must not:
  • be subject to supervisory requirements, or
  • have any other provisions on their registration that may adversely impact performance in the role.
• have at least five years full-time equivalent relevant clinical experience, including the treatment and/or management of work-related injuries
• within the last three years:
  • have been in clinical practice for a minimum of 8 hours per week or
  • have completed at least five injury management consultations (including file reviews) per 12-month period of approval
• have demonstrated working knowledge of the NSW workers compensation system
• have demonstrated high level communication and negotiation skills

2.2 Other criteria

In considering whether an applicant is to be approved as an IMC, SIRA may consider any relevant information. This may include whether the applicant has:

• within the last ten years:
  • had any demonstrated breach of legislation, guidelines or fee schedules in the NSW workers compensation system or in any other statutory insurance compensation system in any Australian jurisdiction
  • been subject to a complaint made to insurance, compensation or health authorities, government agencies or statutory bodies regarding the applicant’s conduct:
    • in any role in any insurance compensation system in any Australian jurisdiction and
    • in the provision of health services
  • for previously approved IMCs, had their approval as an IMC revoked by SIRA
  • been convicted of any criminal offence or have any pending criminal charges
  • demonstrated behaviour that a reasonable person would consider to affect the practitioner’s ability to undertake the role with impartiality and fairness or negatively impact the integrity of the personal injury compensation schemes in NSW.

Declaring any matters relating to the criteria above will not automatically lead to an approval not being granted. Applications are assessed on a case by case basis, taking into account the level of risk the matter may pose to individuals or the scheme.

Appendix 1 - Conditions of approval

The approval by SIRA of an IMC is subject to the following conditions of approval under s45A (2) of the 1998 Act.

1. Professional eligibility condition

• continue to meet applicable eligibility criteria under 2.1 of the Injury management consultant approval and regulatory framework

2. Legislative conditions

• undertake the functions of the IMC in accordance with the Workers compensation guidelines
• comply with all legislation, guidelines and fee schedules in the NSW workers compensation system and in any insurance compensation system in any Australian jurisdiction
• comply with all relevant confidentiality, privacy and health information laws, including but not limited to the Health Records and Information Privacy Act 2002 (NSW), and the Privacy Act 1988 (Cth).

3. Professional conduct conditions

• comply with all applicable professional standards and codes of conduct including but not limited to the Medical Board of Australia’s Good Medical Practice: A Code of Conduct for Doctors in Australia
• act without bias and in a way that does not give rise to an apprehension of bias in the performance of their responsibilities, including refrain from engaging in activities or publicly expressing opinions that might be perceived to compromise the practitioner’s ability to deal in an independent and unbiased way with matters referred to them in their capacity as a SIRA IMC
• agree not to provide treatment services to workers referred for an injury management consultation
• not ask for or accept any inducement, gift, or hospitality from individuals or companies, or enter into arrangements that could be perceived to provide inducements, that may affect, or be seen to affect, their ability to undertake the role of an IMC in an impartial and unbiased manner
• declare any real, perceived or potential conflict of interest to the referrer at time of referral or, if a conflict or potential conflict arises after the referral, as soon as it arises
• have in place robust systems and processes to ensure all conflict of interest issues are considered and mitigated
• act in an ethical, professional and considerate manner when communicating with any other parties in relation to the worker about their recovery
• not make a statement or imply that they are acting on behalf of SIRA, or representing SIRA in any capacity, including in advertising, media or any publication or forum, including presentations at conferences or seminars.

4. Reporting conditions

• if unable to contact the nominated treating doctor after three attempts, inform the insurer/referrer and document the attempted contacts in the IMC report
• ensure reports are in accordance with the Workers Compensation Guidelines
• ensure that reports are completed to a reasonable standard of care and diligence, including that they are tailored to the individual circumstances of the worker
• provide reports to the referrer within 10 working days of the appointment/review, or within a different time frame if agreed between the parties.

5. Communication with SIRA conditions

The IMC must inform SIRA within 7 days if they become aware that:

• information provided to SIRA in their application, including the Declaration was incorrect or incomplete
• they have breached a condition of approval as an IMC
• they have breached legislation, guidelines or fee schedules in the NSW workers compensation system or in any insurance compensation system in any Australian jurisdiction
• a complaint has been made about them to insurance, compensation or health authorities, government agencies or statutory bodies regarding their conduct:
  • in any role in any insurance compensation system in any Australian jurisdiction and
  • in the provision of health services
• they have been convicted of any criminal offence or have any pending criminal charges.

An IMC must:

• provide and maintain an email address to be used for all written communication from SIRA
• provide accurate contact details to SIRA and notify them in writing (including electronically) within 14 calendar days of any change to name or contact details (as these appear on the SIRA website list of approved IMCs as a public register)
• provide any information requested by SIRA for the purpose of performance monitoring and quality assurance
• respond to complaints with full and accurate details and, when indicated, comply with the remedial action to be taken.

6. Administrative conditions

• possess or have access to sufficient resources and infrastructure to undertake all administrative activities necessary to undertake the role of an IMC
• establish and maintain appropriate and secure record management systems to manage work and maintain records and data lawfully and efficiently
• comply with all legal requirements for practice, including relevant policies and codes of conduct
• submit invoices to the insurer within 30 calendar days of the service provided and comply with the SIRA itemised invoicing requirements
• participate in SIRA’s performance framework for IMCs in relation to the conditions of approval
• complete any other training specified by SIRA to the standard required by SIRA, within the prescribed timeframe and at the IMC’s own expense.