Nominal Insurer Audit Report - January 2023

January 2023

1. Executive summary

SIRA has observed a deterioration of the Nominal Insurer (NI) return to work (RTW) rates and financial sustainability for several years. In response to falling claims management performance, two independent reviews (Dore 20191 and McDougall 20212) and its own independent Governance and Culture report, icare has developed and is implementing the icare Improvement Plan.

With heightened concerns on falling RTW rates, SIRA conducted an audit of icare’s management of the first four weeks of 50 NI workers compensation claims. SIRA has conducted this audit in accordance with powers provided in section 202A of the Workers Compensation Act 1987 (the 1987 Act).

The audit sample consisted of 50 workers compensation claims, 33 of which were significant physical injury claims and 17 of which were significant psychological injury claims notified in July 2022.

SIRA’s audit tool (Appendix A) comprised of 26 criteria split across three key areas:

• Data Accuracy
• Compliance with Legislation
• Qualityand Compliance with Standards of Practice.

Four frontline Case Managers were interviewed at each Claims Service Provider (CSP) to understand their comprehension and application of the Standards of Practice, and any perceived barriers to managing claims.

SIRA would like to thank icare and its CSPs for their participation and cooperation with this audit.

1.1 Summary of key findings - data accuracy

SIRA relies on icare to provide accurate data in line with the Workers Compensation Insurer Data Reporting Requirements (WCIDRR) to inform insights on the NI’s performance. SIRA scored the following areas for data accuracy during the audit:

It is clear from the audit score and discussions with CSP representatives, there was little consistency in understanding of date claim made data field as defined in the WCIDRR.

1.2 Summary of key findings - compliance with legislation

When a notification of a workplace injury is received by an insurer, the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act) outlines actions that insurers must complete within prescribed timeframes. The compliance measures that SIRA assessed during this audit were:

1.3 Summary of key findings - quality and compliance with Standards of Practice

Research confirms a strong link between effective early intervention, positive recovery, and improved return to work outcomes for workers following an injury. Tailoring action and support to the worker’s needs, and clear communication about claim and return to work processes in the first four weeks following injury, establishes trust between the insurer, a worker, and their employer to optimise recovery and work outcomes.

SIRA assessed the following aspects of a claim and their alignment with the expectations set in SIRA’s Standards of Practice on Injury Management Plans (IMPs) and early intervention (Standards of Practice 12, 33 and 34).

IMPs scored poorly with the audited plans mostly generic, often missing detail, strategies, stakeholder actions and goals. These IMPs were not viewed as a plan and reference document for the workers recovery and RTW, rather they focussed on worker obligations, implying use as a compliance tool.

1.4 Audit outcome

The individual claim audit criterion scores ranged between 30 per cent and 100 per cent, with the overall audit score calculated as 74.6 per cent. Both physical and psychological claims displayed a wide variance in audit scores, with physical claims averaging 75.2 per cent and psychological claims slightly lower at 73.3 per cent.

Key findings and recommendations can be found in subsequent sections of this report.

1.5 Summary of key observations - Guidewire

The audit team experienced various access and response issues in the Guidewire system, with the system intermittently freezing and becoming unresponsive.

SIRA noted the feedback from one Case Manager of: “some days are good, and some days are bad, various times during the days are slower than others, it is unpredictable.”

This feedback was consistent with that from other claims management staff.

Variable system performance has the potential to create operational barriers, particularly when a case manager is in conversation with a worker but cannot access information on Guidewire.

It was noted on multiple claims that there was missing documentation and file notes. Auditors were frequently advised that case manager had these documents saved on their computers or emails, but these were not copied onto the Guidewire claim record. These system work arounds raise concerns about information security as case managers may have personal information insecurely stored on their computers.

1.6 Summary of commentary - Case Manager interviews

SIRA interviewed 16 case managers involved in the management of claims subject to the audit (four at each CSP). The purpose of these interviews was to provide SIRA with insights and experience from these frontline staff.

Experience in the management of workers compensation claims for those interviewed ranged from five months to over 20 years. Caseloads varied from 48 to 83 claims, with case managers with lower caseloads focussing on primary psychological injuries. The case managers reported feeling generally supported in their role.

While many case managers were generally familiar with most of the principles within the Standards of Practice, they did not demonstrate specific knowledge or familiarity with Standards 33 and 34. Case manager feedback on the application of IMPs correlated with the audit findings that this document was more likely used as an obligations and compliance tool than a road map to manage return to work. More experienced case managements noted the value of these in injury management and in alignment with Standard of Practice 12.

In respect to the barriers the case managers faced in their day-to-day work, the following were common response themes:

• Guidewire functionality
• High caseloads and insufficient time
• Inability to tailor templates
• Workers and stakeholders thinking the NI/CSP is a spam caller
• Obtaining IME appointments.

2. Introduction

SIRA regulates NSW mandatory insurance schemes including the NSW workers compensation scheme. The Nominal Insurer, managed by Insurance and care NSW (icare), is the largest insurer in the NSW workers compensation scheme, accounting for approximately 67 per cent of all claims.

icare outsources the management of workers compensation claims to Claim Service Providers (CSPs). The CSPs for the NI are Employers Mutual Limited (EML), Allianz, QBE and GIO. Deterioration of the NI return to work (RTW) rates and financial sustainability has been of concern to SIRA for several years. In response to falling claims management performance, two independent reviews (Dore 20191 and McDougall 20212) and its own independent Governance and Culture report, icare has developed an Improvement Plan. This has two sub programs with the Nominal Insurer Improvement Plan, with a key stream of work focussed on early claims management intervention to lift RTW rates.

3. Purpose

SIRA announced in September 2022 that it would conduct quarterly audits on up to 50 NI claims, with the first audit beginning in October 2022. The purpose is to ensure compliance and performance in line with the NSW workers compensation legislation, Guidelines, Standards of Practice and Customer Service Conduct Principles.

Evidence shows that recovery at work supported by early intervention promotes the best outcomes for workers injured at work. SIRA has provided guidance to all workers compensation insurers to focus on early return to work and intervention in the first four weeks of a claim through Standard of Practice 34 Return to work - early intervention.

SIRA wanted to ensure that Standard of Practice 34 and other applicable Standards, are utilised, and reflected in the claims managed by icare. SIRA conducted an audit of the first weeks of activity on 50 NI claims against but not limited to:

• Workers Compensation Act 1987 (1987 Act)
• Workplace Injury Management and Workers Compensation Act 1998 (1998 Act)
• Workers Compensation Guidelines
• SIRA’s Standards of Practices
• Workers Compensation Insurer Data Reporting Requirements.

SIRA has conducted this audit in accordance with powers provided in section 202A of the Workers Compensation Act 1987 (the 1987 Act).

4. Scope

The October 2022 audits were conducted on site at each CSP using icare’s ‘Guidewire’ claims management system. SIRA reviewed claims lodged in July 2022, allowing an up-to-date reflection of actions undertaken icare’s Nominal Insurer Improvement Plan.

4.1 Audit criterion

SIRA’s audit tool (Appendix A) comprised of 26 criteria split across several key focus areas in relation to:

• Performance and compliance relative to legislative obligations
• Application of Standard of Practice 12 - Injury Management Planning
• Application of Standard of Practice 33 – Managing Psychological Injuries (where applicable)
• Application of Standard of Practice 34 – Return to Work and Early Intervention
• Claims data accuracy and reflective of relevant information on the file in application of related legislation, guidelines, and Standards of Practice.

4.2 Review period

The review period incorporated actions on the file from the date the claim was entered into the insurer system (DEIS). SIRA reviewed all available evidence on file regarding the management of claims and return to work activities in the first four weeks from receipt of each claim.

The audit also examined any determination for liability for medical requests/expenses received:

• In the first four weeks of the life of the claim, and
• The period for liability determination for the treatment fell outside of the first four weeks.

The audit also examined any determination for liability of a claim in totality once:

• The claim has been made (following the issuing of a reasonable excuse to the worker) in the first four weeks of the life of the claim, or
• Where the period for determination fell outside of the first four weeks.

4.3 Audit sample

Fifty claims were audited across the NI split by claims market share for each CSP. The sample parameters were:

• All claims were deemed to be a significant injury as defined by legislation
• 33 primary physical injury claims were reviewed
• 17 primary psychological injury claims were reviewed
• A mix of either liability initially reasonably excused, provisionally accepted or accepted outright
• Include claims certified with either no capacity for work or certified with capacity but had not returned to work.

4.4 Case manager interviews

Four frontline case managers responsible for the claims were interviewed at each CSP. Questions covered their experience/ background in managing personal injury claims, resources available to them, their application and understanding of the Standards of Practice, and perceived barriers to managing claims.

5. Audit findings

The audit criterion has been broken down into three key areas:

• Data Accuracy
• Compliance with Legislation
• Quality and Compliance with Standards of Practice.

On occasions where specific criterion is not applicable to a claim, this has been commented upon within the respective section.

5.1 Data accuracy

SIRA relies on icare to provide accurate data in line with the WCIDRR to inform insights on the NI’s performance. SIRA reviewed the following areas for data accuracy during the audit:

• Date Entered in Insurer System (DEIS)
• Significant injury date
• Date claim made.

5.1.1 Date Entered in Insurer System (DEIS)

Legislative timeframes for liability decisions and payment of weekly entitlements commence from notification of an injury to an insurer. As a regulator, SIRA’s predominant reference for assessing and measuring parameters in the data is from the date the claim is entered into the insurer claims management system (DEIS). A key assumption is that the date the insurer is notified is the date the claim is entered into the insurer system.

In the audits SIRA assessed the time it took for a notification of a claim received by icare to be entered into icare’s Guidewire claims management system.

Notification of injury/claims were received in three ways:

• Claims lodged on icare’s portal were observed to appear the same day in Guidewire
• Claims that were notified via phone were generated in the system shortly (the same day) after the call
• Claims could be emailed through to an icare address or the CSP case manager directly. This process had the longest delays from NI notification to entry into Guidewire. It was noted that one claim reviewed took approximately one week to be entered onto Guidewire. This injury notification was lodged via email (listed in icare’s website) and remained in icare’s notification system for a week before being actioned.

Overall, 90 per cent of claims received by icare were entered into Guidewire on the same day, or the next business day if received after 4pm. Of the remaining 10 per cent, four claims received before 4pm were entered the next business day and one claim was entered into the Guidewire system one week after receipt.

5.1.2 Significant injury date

A significant injury as defined by Section 42 of the Workplace Injury Management and Workers Compensation Act 1998:

• means a workplace injury that is likely to result in the worker being incapacitated for work for a continuous period of more than seven days, whether or not any of those days are workdays and whether or not the incapacity is total or partial or a combination of both.

The importance of the significant injury date is that this date triggers timeframes for insurers to complete key early intervention actions such as initial stakeholder contacts and injury management plans.

The significant injury date was completed with 90 per cent accuracy. SIRA noted that on two occasions the significant injury date, was the date of NI notification, but due to the claim being entered in Guidewire the following day, the Guidewire system prevented the correct significant injury date being accurately reflected. On one claim a file note was observed to this effect, clearly stating the correct date and the system limitation to correctly reflect it.

SIRA notes the CSPs generally worked off the DEIS and therefore often met required action timeframes that are trigged by the significant injury date.

5.1.3 Date claim made

Section 260 of Workplace Injury Management and Workers Compensation Act 1998 states that:

• A claim must be made in accordance with the applicable requirements of the Workers Compensation Guidelines.

The Workers Compensation Guidelines Part 3 Making a Claim outlines the minimum requirements for making a claim for workers compensation including when there is a requirement for a claim form. The determined date a claim has been made is reported to SIRA as part of icare’s monthly data submission.

The date claim made data field was completed accurately on 14 per cent of claims reviewed. While it was noted that on three occasions the date claim made was correctly file noted, it was not entered into Guidewire correctly. On one occasion the date claim made was the same date as the initial notification to the NI and the Guidewire system would not allow this field to predate the DEIS.

In all but two cases, the date claim made was either blank or reflected the end of the provisional liability acceptance period.

Due to the variation in application, SIRA queried managers at CSPs on their understanding of the date a claim is made. Varied responses were provided including quoting reference to when the claim needs to be ‘duly made’ or when a completed claim form is received. One CSP explained the claim was considered made at the end of provisional liability, when all the information was available to accept liability for the injury.

SIRA found that there was little consistency in understanding this data field in those interviewed. SIRA acknowledges the difference in interpretation of date claim made and will provide further clarity on the date claim made data field to insurers.

5.2 Compliance with legislation

When a notification of a workplace injury is received by an insurer, the 1998 Act outlines actions that insurers must complete within prescribed timeframes. The compliance measures that SIRA assessed during this audit were:

• Initial contact with stakeholders (worker, employer, Nominated Treating Doctor (NTD))
• Initial liability decision
• Insurer make reasonable efforts prior to applying a ‘Reasonable Excuse’ on a claim
• Review of liability on claims placed under a ‘Reasonable Excuse’
• Payment of weekly benefits within seven days
• Liability decision on treatment requests
• Advising relevant stakeholders on liability decisions for treatment requests
• Issuance of Injury Management Plans.

5.2.1 Initial contact with stakeholders

Section 43 of the Workplace Injury Management and Workers Compensation Act 1998 states that initial contact with workers, employers and NTDs (where required) is to be completed within three working days of the insurer being notified of the injury being deemed a significant injury. All claims reviewed by SIRA were deemed to be a significant injury.

The initial stakeholder contact criteria were applicable on all claims. For these criteria to be met, either:

• contact was established for workers, employers, and NTD within the three business days, or
• multiple attempts over multiple days (via phone or email) was required to be documented, or,
• a file note stating clearly why contact was not required. For example, in the case where the injury is clearly work related, the treatment plan is clear, and no barriers have been identified with RTW, NTD contact may not be required at this stage.

A summary of observations is below.

Table 1: Summary of initial stakeholder contacts

5.2.2 Initial liability decision

Section 267 of the Workplace Injury Management and Workers Compensation Act 1998 states:

• Provisional weekly payments of compensation by an insurer are to commence within 7 days after initial notification to the insurer of an injury to a worker unless the insurer has a reasonable excuse for not commencing those weekly payments.

For making an initial liability decision within seven days of notification, 98 per cent compliance was observed, noting the only claim not meeting conformance was the claim entered in icare’s system one week after receipt. Consideration of the accuracy of the liability decision in reference to the claim information received was out of scope for this audit criterion.

5.2.3 Insurer make reasonable efforts prior to applying a ‘Reasonable Excuse’ on a claim

SIRA assessed claims in line with the Standards of Practice to ascertain insurer attempts to resolve any information gaps prior to reasonably excusing liability for a claim. For example, attempting to clarify the diagnosis and/or circumstances of injuries and attempts to obtain a copy of the certificate of capacity, prior to reasonably excusing the claim based on insufficient medical information.

A summary of observations is below.

Table 2: Summary of insurer efforts to obtain required information prior to application of a ‘Reasonable Excuse’

5.2.4 Review of liability on claims placed under a ‘Reasonable Excuse’

SIRA’s Standard of Practice 3: Initial liability decisions – general, provisional, reasonable excuse or full liability, provides context to the legislation in that once a reasonable excuse applied to a claim has been resolved, insurers have seven days to commence weekly payments under provisional liability or fully accept or deny liability within 21 days.

Of the claims assessed, this criterion only applied to 11 claims that were reasonably excused, and had the reasonable excuse resolved in the first four weeks. A summary of observations is below.

Table 3: Summary of insurer review of claims placed under a ‘Reasonable Excuse’

5.2.5 Payment of weekly benefits within seven days

Where provisional or full liability is accepted, Section 93 of the Workplace Injury Management and Workers Compensation Act 1998 states:

• Weekly payments of compensation are to commence as soon as practicable (but not later than 21 days) after the claim for compensation is duly made.

As outlined in 5.2.2 above, insurers are required to commence weekly benefit payments within seven days of a claim having provisional/full liability accepted.

In order to commence weekly payments, the Pre-Injury Average Weekly Earnings (PIAWE) is required to be calculated. Insurers are to make reasonable efforts to obtain wage information and are expected to make adjustment payments within seven days upon receipt of wage details.

Insurers on occasion will calculate an ‘interim PIAWE’ if earning details are not available to determine a PIAWE within the first seven days.

Calculation of correct PIAWE benefits was out of scope for this audit.

Generally, with small employers, the insurer initiates weekly payments directly through the employer to expedite or continue wage payments during the workers usual pay cycle, averting delays while obtaining bank and taxation details.

With large employers, the NI and employers have wage reimbursement schedule agreements in place. icare provides written confirmation advising employers of the liability decision and the weekly benefit amount to be paid to the worker. The employer pays the worker during their usual pay cycle and claims the money back from the NI on a regular basis.

Due to the nature of how a wage reimbursement schedule works, weekly benefit payments are not made within seven days to the employer by the NI. SIRA views the utilisation of wage reimbursement schedules to be compliant if there was evidence on file that the insurer and employer have an agreement in place, and a direction is sent to the employer to commence weekly benefit payments.

A summary of observations is below.

Table 4: Summary of insurer paying weekly benefits on claims:

5.2.6 Liability decisions on treatment requests

In line with section 279 of 1998 Act, insurers are required to review and make a liability determination on all medical treatment, hospital and workplace rehabilitation provider services received within 21 days.

This audit observed that CSPs determined all treatment requests received in the first four weeks within timeframe.

5.3 Quality and compliance with Standards of Practice

Research confirms a strong link between effective early intervention, positive recovery and return to work outcomes. Tailoring action and support to the worker’s needs, and clear communication about claim and return to work processes in the first few weeks following injury, establishes trust between the insurer, a worker, and their employer to optimise recovery and work outcomes.

SIRA has developed 34 Standards of Practice to provide clarity and guide insurers identify and manage the complexities of claims. During this audit, SIRA reviewed claims focusing on applicable Standards of Practice related to the first four weeks in managing a claim, in particular relating to:

• Standard of Practice 12 - Injury Management Planning
• Standard of Practice 33 - Managing Psychological Injuries
• Standard of Practice 34 - RTW and Early Intervention.

SIRA assessed the following aspects of a claim and their alignment with the intention of SIRA’s Standards of Practice:

• Quality of initial stakeholder contacts
• Risk identification and planning
• Injury management planning and Plans
• Review of identification of risks, strategies, and implementation of actions
• Updating and reissuance of injury management plans
• SIRA’s Customer Service Conduct Principles.

5.3.1 Injury management planning

SIRA looked at the following criteria to understand if injury management planning had commenced upon notification of injury:

• Exchanging information about risks, goals, and work
• Discuss potential/appropriate interventions and supports
• Monitoring response to treatment and liaising with the worker and providers if treatment is not contributing to the worker’s goals and outcomes.

It was observed through file notes and actions on the file, 76 per cent of the time injury management planning covering all the above points commenced upon receipt of a notification of injury.

5.3.2 Quality of initial stakeholder contacts

As reported in the initial worker and employer contact (5.2.1), icare was compliant with the timeliness of these initial contacts. The timeliness of NTD contacts, where appropriate, were observed at under 50 per cent.

In line with the applicable principles in Standards of Practice 33 and 34, SIRA reviewed the quality of the initial contacts completed on claims regardless of whether the contacts were made within the first three days or thereafter.

When each contact was assessed, all criteria applicable had to be addressed to ‘meet expectations’ in either a file note or written correspondence.

Table 5: Applicable criteria for initial stakeholder contacts

SIRA auditors reviewed information on file, including file notes, email correspondence and documentation, to assess the tone and context of conversations with stakeholders. SIRA determined call recordings were out of scope for this audit. SIRA has the expectation that all relevant information is captured in Guidewire in the form of file notes, emails and documentation so it can be readily accessed if the case manager assigned to the claim is unavailable.

When SIRA assessed this criterion, it was observed on multiple claims that there was an existing case manager and employer/worker relationship, particularly with large employers. SIRA assessed these contacts as meeting expectations in the absence of clarification of ‘rights and obligations’ and ‘explanation of the claims process’ as these were considered to be already well understood by stakeholders.

SIRA observed that on occasion a file note template was used for initial contact with workers and employers. These templates were comprehensive however not always fully completed. A summary of observations is below.

Table 6: Summary of insurer quality of initial stakeholder contacts:

Table 6: Summary of insurer quality of initial stakeholder contacts

5.3.3 Risk identification and planning

SIRA’s Standard of Practice 34 has highlighted four domains for insurers to gather information on a claim to identify risks of delayed recovery and return to work. These domains are:

• Personal
• Workplace
• Insurance
• Healthcare.

Insurers are also to ensure they screen for biopsychological factors, to identify claims where workers are at an elevated risk of developing a secondary psychological injury, within these four domains.

Once the insurer has gathered information on a claim across these four domains, insurers were required to complete the following actions:

• Analyse and identify risks
• Identify strategies to address risks
• Implement identified strategies to address risks
• Appropriately allocate and prioritise the claim.

For insurers to meet these actions, documented evidence is required on file to demonstrate the elements of these four actions have been considered.

Note: On some claims there was no clear risk and/or strategy identification, however strategies identified and/or implemented on the claim were deemed appropriate for the claim. In these circumstances a claim may not meet the criterion for one of the following actions, however still meet the criterion on a subsequent action.

Action 1 – Analyse and identify risks

It was observed on occasions:

• Risk identification was completed during initial contacts and documented in file notes
• Summary file notes clearly highlighting identified risks
• Risk assessment templates were on file, however not completed
• No risk assessment was completed in some cases.

SIRA identified 74 per cent for this criterion.

Action 2 - Identify strategies to address risks

It was observed on occasions:

• Strategies were identified during initial contacts
• Summary file notes identifying strategies to address risks were present
• Risks identified did not have strategies identified to address the risk
• No strategies identified on the claim at all

SIRA identified 71 per cent compliance with this criterion.

Action 3 - Implement identified strategies to address risks

It was observed on occasions

• Strategies were implemented appropriately and timely
• Strategies were not implemented
• Strategies were implemented, however not timely (did not meet criterion)

SIRA identified 73 per cent compliance with this criterion.

Note that two claims were not applicable to actions 2 and 3 as one had been withdrawn and the other the claimant was in hospital at time of notification.

Action 4 - Appropriately allocate and prioritise the claim

When a claim is entered into Guidewire, the system through artificial intelligence scans several data points and allocates the claim into one of the four following segmentations:

• Guide: Notification/medical only and low risk claims
• Support: Significant injury claims – incapacity over one week or risks have been identified to impact recovery and RTW
  Specialied: Primary psychological injuries, complex injuries or injuries sustained from traumatic events
• Workers Care: Severe injuries such as brain, spinal cord, amputations, burns and blindness.

Once Guidewire has made its recommendation for segmentation, an injury management advisor at the CSP will review that claim information and either accept or change the segmentation categorisation where appropriate (usually the same day, or the following business day). A change in segmentation, for example from guide to support, was usually followed by a change in case manager to manage the claim.

It was also noted that Guidewire continuously reviewed data points to make suggestions for re- segmentation that triggered a review by the CSP injury management advisor.

In all but one claim, the segmentation appeared in accordance with icare’s requirements. One claim was reallocated, however not actioned in a timely manner, potentially compromising the early injury management on the claim.

5.3.4 Review of identification of risks, strategies, and implementation of actions

Throughout a claim, circumstances change, such as treatment, risks and barriers for recovery and RTW, and RTW goals. SIRA reviewed claims throughout the first four weeks to understand if:

• any new risks and barriers were identified across the four domains (outlined in part 5.3.2)
• any new strategies were developed to address new risks identified
• new strategies implemented were done so in a timely manner.

These criteria were applicable to 31 claims, for which all three points above were required to be completed to meet conformance.

It was observed that 65 per cent of these claims had new risks or barriers identified. However appropriate strategies were either not identified or not implemented in a judicious timeframe (e.g., referral to a workplace rehabilitation provider services).

5.3.5 Injury management plans

As outlined in Standard of Practice 12, insurers are to develop an IMP within 20 days of the significant injury date. This IMP is to be developed in consultation with, and issued to, all relevant stakeholders involved in a worker’s RTW. The IMP is to be forwarded within 20 business days of a claim being identified as either a significant injury or likely to be a significant injury, in accordance with Standard of Practice 12-Injury management plans. Of the claims reviewed it was noted:

• Ninety per cent of claims that were required to have an IMP developed, were compliant within timeframes
• Three claims had IMPs that were completed after the 20-day timeframe (not compliant)
• One non-compliant claim had no evidence of an IMP on file
• One claim had a single generic template generated with no letters addressed to stakeholders, appearing not to be issued to stakeholders (not compliant)
• Two claims had been withdrawn and therefore an IMP was no longer required to be developed.

Development of an IMP should be focussed on coordinating and managing treatment, rehabilitation and, if necessary, retraining of a worker to support a timely, safe, and durable return to work. An IMP is designed for case managers to share this information with all stakeholders involved in a claim.

It was observed that all CSPs used an icare template to develop IMPs with Guidewire having some functionality to prefill parts of the template. In one window in Guidewire, titled ‘Plan’, case managers were able to enter actions and strategies specific to the claim. Each item needed to be manually selected to be included on each IMP. A separate version of the IMP and covering letter was generated for each applicable stakeholder.

SIRA reviewed all initial IMPs on file against the principles of Standards of Practice 12, 33 and 34. Each IMP needed to meet all applicable criteria in the table below to be deemed compliant.

Table 7: Applicable criterion for IMPs

The quality of assessed IMPs in line with applicable Standards of Practice was low, generic, and often missing detail, strategies, stakeholder actions and goals. The IMPs audited were not used as a plan and reference document for the workers recovery and RTW. These IMPs frequently listed obligations only for the worker, implying use as a compliance tool.

IMPs were frequently completed seven to ten days after initial notification of injury. The IMPs audited generally had minimal information and did not meet the requirements of SIRA’s Standards of Practice This early IMP development appeared to the audit team to be driven by business processes. While generating an IMP early in the claim is beneficial, it risks overlooking stakeholders and crucial information, thus requiring an updated IMP to be issued as this information is obtained. On many claims where the IMP was issued early, an updated IMP was not created as further information became available. IMPs that were completed closer to the 20-day milestone were observed to more likely meet the Standards of Practice.

It was noted that the strategies documented in the Guidewire ‘Plan’ window were often of value to the claims injury management planning, however, often did not transpire onto the IMP.

A similar issue arose with detailing the current treatment a worker was undertaking onto the IMP. As initial allied health treatment did not require formal approval, these provider details were not usually captured into the part of Guidewire that the treatment section of the IMP generated, resulting in this section missing key stakeholder engagement.

Many IMPs audited were frequently issued without consultation with or sent to the NTD.

The IMP template contained a generic statement in supporting documentation noting “this plan will be reviewed if required”. While those experienced in workers compensation may understand this statement, the majority of stakeholders would have little insight into this. Clearer definitions and parameters need to be provided as to when the IMP will be reviewed.

In discussions with icare and CSPs on site, the failings with this criterion were recognised and is intended to be a key focus into 2023.

Please see the table below for further observations.

Table 8: Summary of insurer quality of IMPs

5.3.6 Updating and reissuance of IMPs

Standard of Practice 12 outlines the requirement for insurers to review an IMP in line with any changes to the injury and/or claim. In some instances, the current IMP issued on the claim, if completed in line with the Standard, was not required to be reissued.

SIRA reviewed if the IMP was required to be updated, and re-issued, in line with the new risks/barriers and strategies identified and implemented along with any other changes (e.g., treatment or goals) on the claim in the first four weeks.

Due to a number of IMPs being issued early on a claim, SIRA deemed it appropriate that 19 IMPs were required to be updated in line with new information received on the claim. Of the claims reviewed it was assessed that eight (42 per cent) were deemed to have been appropriately updated and issued in accordance with new information available on the claim.

5.3.7 Advising relevant stakeholders on liability decisions for treatment requests

Standard of Practice 4 - Liability for medical or related treatment requires the insurer, in a timely manner, to advise relevant stakeholders of a liability decision for treatment.

SIRA found that CSPs were compliant 93 per cent of the time.

5.3.8 SIRA’s Customer Service Conduct Principles

SIRA has developed Customer Service Conduct Principles that all insurers in the scheme (including the NI) have attested to. SIRA’s Customer Service Conduct Principles include:

1. Be easy to engage and efficient
2. Act fairly, with empathy and respect
3. Resolve customer concerns quickly, respect customers’ time and be proactive
4. Have systems in place to identify and address customer concerns
5. Be accountable for actions and honest in interactions with customers.

Grievances, complaints, and issues raised

SIRA reviewed any grievances or complaints raised in the first four weeks of a claim and assessed how they were managed against these principles. A summary of issues raised were:

• Complaints around liability decisions and communication of these decisions on claims
• Pre-injury average weekly earnings calculations
• Complaints about not receiving payment of weekly benefits from insurers/employers.

It was noted that 12 matters were raised of which eight (67 per cent) were managed in line with these principles. Issues that did not meet SIRA’s Customer Service Conduct Principles were around calculation and payment of weekly benefits.

CSP’s accountability for actions

SIRA also reviewed if CSPs completed all actions, that they said they would complete, throughout the first four weeks of the claim (e.g., call the worker when they said they would). This criterion was met with 80 per cent compliance over 44 claims applicable.

6. Case manager interviews

SIRA interviewed 16 case managers who managed the claims subject to the audit (four at each CSP). The purpose of these interviews was to provide SIRA with insights and experience from these frontline case managers.

SIRA appreciated the availability, time and information provided by case managers during their interviews. For the confidentiality of the case managers interviewed, only overarching scheme insights are provided in this report.

SIRA asked case managers about the following areas:

• Experience and background related to managing workers compensation claims
• The availability of resources to support them in performing their role
• Changes in the way claims have been managed in the past six to twelve months
• Understanding and confidence in implementing of Standard of Practice 34 – RTW and Early Intervention
• Confidence in managing psychological injury claims
• Understanding of Standard of Practice 33 – Managing Psychological Injury Claims
• How case managers use IMPs
• Utilisation of workplace rehabilitation providers
• Barriers/issues faced when managing claims

A summary of insights obtained from case manager interviews is below.

6.1 Experience and background

SIRA wanted to understand the current experience and background of frontline case managers who were managing claims for the NI. Of the case managers interviewed it was noted they had:

• Experience in managing workers compensation claims ranged from five months to over 20 years’ experience. Those with greater experience included history in self, specialised and TMF schemes.
• The additional following additional qualifications and/or experience was noted:
  • Experience managing other types of personal injury or indemnity claims
  • Allied health and rehabilitation degrees and work experience
  • Registered nurse degrees and work experience
  • RTW coordinator accreditation and work experience
  • Personal Injury Education Foundation (PIEF) qualifications
  • Workers compensation coding course accreditation.

6.2 Resources

SIRA wanted to understand if case managers felt supported and had adequate resources to manage claims. Of the case managers interviewed, it was noted they:

• have varying caseloads from 48 to 83 claims comprising of a mixture of physical and psychological claims. Case managers with lower caseloads tend to manage more primary psychological injury claims
• regularly utilise knowledge and support from their colleagues when managing complex claims
• felt sufficient resources and knowledge articles were available to help them complete their role
• reported specific training is provided by their CSP and/or icare.

6.3 Changes in the last six to twelve months

SIRA asked case managers about any changes in the way they manage claims in the last six to twelve months. The aim of this question was to establish whether Standard of Practice 34, which was released in April 2022, had influenced case management practice. While some case managers noted no change in the way they manage claims in the last six to 12 months, other responses noted:

• an increased focus on RTW
• a focus on contacting workers and stakeholders via phone instead of via email
• emphasis on case conferencing and contacting NTDs
• increased efforts on actioning workplace rehabilitation provider and factual investigation referrals sooner.

Some of the other changes mentioned by case managers included:

• Growing number of primary psychological injury claims and secondary psychological injuries.
• Use of icare templates replacing CSP templates
• An increase in their caseloads
• Growth in experience and knowledge has improved ability to manage claims.

6.4 Understanding and implementing Standard of Practice 34

When queried about their understanding and implementation of Standard of Practice 34, case managers were generally not familiar with the Standard specifically, however, were familiar with most of the principles within the Standard. Case managers spoke to the importance of:

• identifying suitable duties and engaging workplace rehabilitation providers early in the claim to commence RTW
• the actions required and conducted on a claim in the first four weeks have a long-term impact on the outcomes of a claim
• contacting and following up NTDs to gather information for an injury/claim
• gathering information early in the claim to understand underlying risks/issues to promote early treatment and interventions
• utilising updated early contact guides.

6.5 Confidence in managing psychological claims and implementing Standard of Practice 33

When queried about their understanding and implementation of Standard of Practice 33, case managers were generally not familiar with the standard specifically, however some Case Managers were familiar with some of its principles. The general themes included:

7. General observations

SIRA conducted this audit through direct access to Guidewire provided by icare, on site at each CSP’s Sydney offices over five days. Each CSP uses an identical version of Guidewire to manage claims on icare’s behalf.

Below are observations made by SIRA while conducting the audit of the NI.

7.1 Guidewire

Guidewire is a web-based claims management system that stores all claim and policy information (note SIRA did not look at the policy section of Guidewire as part of this audit), including data coding and documentation attached to each claim.

The audit team experienced various access and response issues in the Guidewire system, with the system intermittently freezing and becoming unresponsive at times. On numerous days auditors would have to restart Guidewire due to it kicking the user out or completely freezing. SIRA noted the feedback from one Case Manager of: “some days are good, and some days are bad, various times during the days are slower than others, it is unpredictable.” This sentiment was echoed by other CSP staff with the cause of the variable performance unknown.

Variable system performance has the potential to create operational barriers, particularly when a case manager is in conversation with a worker but cannot access information on Guidewire.

7.2 Missing documentation and information

It was noted on multiple claims that there was missing documentation and file notes. CSPs frequently advised that these documents/notes did exist, however the Case Manager of the respective claims had these documents on their computers or saved in their emails and were not copied onto the claim. Some case managers reported they use other applications such as One Note to keep records of phone calls and claim developments, and then copy these over to Guidewire.

This process risked crucial documentation and notes being subsequently missing from files. This again raises concerns of Guidewires functionality, where CSP staff potentially found work arounds to manage the ongoing operational issues with Guidewire.

It is also of concern that Case Managers have potentially personal information about claimants insecurely stored on their computers, potentially exposing icare to privacy breaches.

7.3 Templates

Guidewire has all templates inbuilt that CSPs are required to utilise while managing a claim. These documents are designed to populate applicable information from Guidewire, depending on the template selected. All the documentation and templates are created by icare and are generated/completed by each CSP and sent to stakeholders with icare logos.

Once the document has been created through Guidewire, it is stored in Guidewire’s document repository. Guidewire does not reference when or how the document was forwarded to each stakeholder, leaving the assumption it was sent when it was generated. How these documents are sent to stakeholders is unknown.

For the average claim, these templates appear to work well, with the information populated being sufficient for the claim. On more complex claims, CSP staff commented to SIRA that it is difficult to tailor these templates to the specific circumstances of the claim, often leaving them being generic and lacking on appropriate detail (for example IMPs and reasonable excuse liability letters).

8. Recommendations

It is recommended icare consider the findings of this audit in the broader context of the implementation of the icare Improvement Plan.

icare may also consider further investigation of the Guidewire delays experienced by the SIRA audit team and make improvement to the functionality as appropriate.

In addition to icare’s consideration of these learnings, SIRA will use the output from this audit to guide future targeted quarterly audits. In addition to this SIRA, will facilitate a collaborative workshop with the goal to improve injury management planning and injury management plans across the workers compensation scheme.

9. Future Audits

SIRA’s next audit of the NI will be conducted in March 2023.

10. Appendix A - Audit tool