Claims and injury management

Overview

Workplace rehabilitation can be delivered by either an employer and/or their return to work coordinator or a SIRA-approved workplace rehabilitation provider (on behalf of the employer).

To support a worker’s recovery at work, SIRA-approved workplace rehabilitation providers deliver a range of services based on the worker’s circumstances. These include:

• functional and workplace assessments
• advice concerning job modification to facilitate identification of and return to suitable work
• rehabilitation counselling, vocational retraining and assistance with job seeking, when return to work with a new employer is required
• facilitating meetings with relevant parties when a workplace relationship issue is impacting a worker’s recovery at work (‘workplace facilitated discussion’).

The employer’s return to work program outlines the workplace rehabilitation support the employer provides and when workplace rehabilitation provider services are required.

Early engagement

Workers achieve better health and return to work outcomes when employers engage early and provide appropriate support following a workplace incident or injury.

An insurer should give due consideration to the early and timely engagement of a SIRA-approved workplace rehabilitation provider to support a worker’s safe, timely and durable return to work.

Acting early to assess the worker’s needs, establish and build capacity for work, identify suitable work and set meaningful goals is essential to a worker’s successful recovery.

Insurers should use early screening and triage tools to identify a worker’s specific recovery and return to work needs and any risk factors for delayed recovery or return to work. SIRA has provided a template Checklist for Insurers: Risk factors for delayed recovery and return to work – short version to assist in gathering information about modifiable risk factors. A more comprehensive version of the SIRA checklist is also available (Checklist for Insurers: Risk factors for delayed recovery and return to work – full version).

Appropriate action should be taken to provide the required support to coordinate a worker’s injury management and recovery at work activities.

Where risk of delayed recovery or return to work is noted, insurers should consider early referral for workplace rehabilitation services in line with the SIRA Workplace rehabilitation provider approval framework.

Making a referral to a workplace rehabilitation provider

Workplace rehabilitation providers deliver specialised expertise for example, when:

• tailored support is needed to support a worker to stay at, recover at or return to work
• an employer needs assistance to identify suitable work and/or workplace adjustments to accommodate the individual needs of a worker
• workplace issues are impacting recovery through work
• biopsychosocial factors may influence the worker’s recovery and return to work
• a worker needs to obtain work with a new employer and requires the provision of specialist job seeking assistance.

Referral to an approved workplace rehabilitation provider should be in line with the insurer’s injury management program. An insurer may engage a workplace rehabilitation provider of their own choosing, or one nominated by the employer or worker. The worker should be consulted and given the opportunity to nominate or request a change in provider as outlined in the Guidelines for workplace return to work programs.

Only organisations approved by SIRA and issued with a provider number can deliver workplace rehabilitation services in the NSW workers compensation system. A list of SIRA-approved providers can be found on the SIRA website.

When choosing a provider, insurers should:

• ensure the workplace rehabilitation provider has the relevant expertise for the worker’s circumstances
• discuss the type of service needed, purpose of the referral and the provider of choice with the worker and employer
• consider the services the worker has already received to avoid duplication of services when engaging a different provider to support recovery at work.

Workplace rehabilitation services do not include:

• treatment (including therapeutic counselling)
• overseeing or monitoring of a worker’s treatment (including medical management)
• general claims management (for example, determining a worker’s ongoing entitlements or arranging appointments).

Workplace rehabilitation providers should be qualified and competent professionals to facilitate the worker’s recovery at, and return to, work. They are expected to tailor support for the worker with consideration of the biological, psychological and social factors that may influence the worker’s recovery and return to work. They are also expected to take a collaborative approach with the relevant stakeholders and promote the health benefits of good work in managing each individual case.

Workplace facilitated discussion

Communication

The insurer is to discuss the need and reason for referral and choice of provider with the employer, worker and nominated treating doctor (if appropriate).

The insurer should ensure all parties understand the role of the workplace rehabilitation provider and what they can expect from their involvement. The insurer should provide the employer and worker with:

• the name and contact details of the provider
• an explanation as to why the referral has been made
• an indication as to when the workplace rehabilitation provider will make contact
• information that the worker has the right to request a change of provider.

Monitoring of services

The insurer is responsible for approving the provider's plan which includes the worker’s goals, activities and proposed billing to support the worker’s safe, timely and durable recovery at work. The insurer is to ensure that the services approved are consistent with the SIRA Workplace rehabilitation provider approval framework.

The insurer is also responsible for service delivery management consistent with the injury management plan, including monitoring the delivery of services against the approved plan and the achievement of recovery at work outcomes.

Insurers should maintain regular communication and engagement with all stakeholders to ensure that the provider’s rehabilitation plan remains relevant.

Fees and invoices

SIRA does not set maximum fees for workplace rehabilitation providers in the NSW workers compensation system. Providers are required to obtain insurer approval for services and fees before commencing any services.

The insurer is responsible for promptly approving and paying for reasonably necessary services in accordance with section 60 of the Workers Compensation Act 1987 (1987 Act), Standard of practice S10: Payment of invoices and reimbursements and Standard of practice S15: Approval and payment of medical, hospital and rehabilitation services.

For invoicing requirements, refer to Insurer guidance GN 4.3 Invoices and Reimbursements.

Invoices must be submitted by the workplace rehabilitation provider within 30 days of the service provided. The insurer should review any invoices and ensure they include:

• the injured worker’s first and last name, and claim number
• payee name, address, telephone number and email address
• payee Australian Business Number (ABN)
• name of the relevant service provider who delivered the relevant service
• the relevant service provider’s SIRA-issued provider site number
• relevant SIRA payment classification code
• service cost for each SIRA payment classification code and service duration (if applicable)
• date of service
• date of invoice (must be on the day of or after last date of service listed on the invoice).

Insurers should call the workplace rehabilitation provider if they have questions regarding an invoice. Errors or queries can often be resolved quickly over the phone. If telephone contact is unsuccessful, then an email or letter should be sent seeking clarification.

Complaints about a provider

If the employer or worker raises concerns about the workplace rehabilitation provider, these should be addressed according to the insurer’s complaints handling process.

Insurers should consider whether a change to a different provider is required, with serious concerns to be referred for SIRA’s attention. A complaint about a workplace rehabilitation provider can be made by calling SIRA on 13 10 50 or email [email protected].

SIRA considers complaints and complaints management in the evaluation of a provider’s compliance with the conditions of approval.

Provider attendance at worker medical consultations

It is not appropriate for a workplace rehabilitation provider to attend a worker’s confidential medical consultation with their nominated treating doctor.

Where a case conference is required to discuss the worker’s recovery process, insurers should ensure a case conference is scheduled separate to the worker’s medical consultation.

As stated in Standard of practice S16. Case conferencing the insurer should also inform the worker of the intention to arrange a case conference and the reasons for it.

Where a referral is received for a workplace rehabilitation provider to attend a case conference and they have not yet met the worker, the provider should first arrange a meeting with the worker to assess and understand their requirements prior to scheduling a case conference.