GN 6.5 Independent consultants

Published: 12 August 2019

Last edited: 22 December 2023

- GN 6.5 Independent consultants

Application: This guidance applies to exempt workers

Overview

An independent consultant may be called upon to provide an impartial peer review of allied health practitioner treatment in the NSW workers compensation system.

An independent consultant has experience in the assessment, treatment and management of work-related injuries.

This guidance considers:

when to use an independent consultant
selecting and making a referral to an independent consultant
communication with the independent consultant
the report, fees and invoicing.

When to use an independent consultant

A referral to an independent consultant should be considered when an allied health practitioner is requesting treatment that will continue past 16 sessions or, if there is concern about:

the treatment duration, frequency and/or whether treatment is ‘reasonably necessary’
treatment that has continued for an extended period without improvement in functional outcomes, particularly in relation to a worker’s capacity
the treatment approach most likely to achieve positive work outcomes for the worker
barriers to recovery at work and/or psychosocial risk factors for delayed recovery

Before referring to an independent consultant, the insurer should make reasonable attempts to contact the treating allied health practitioner (see Insurer guidance GN 6.4 Allied health practitioners) and discuss any concerns with them. This should be documented in the case file.

Independent consultants cannot:

comment on causation or liability, or
undertake a functional capacity evaluation or any formal assessment of work capacity.

Selecting an independent consultant

A referral to an independent consultant can be requested by the treating allied health practitioner, worker, or the employer, however the insurer must approve and submit the referral.

The insurer should engage an independent consultant using SIRA’s independent consultant referral form. SIRA maintains a register of independent consultants on its website.

When choosing an independent consultant, the insurer should ensure:

that the consultant’s qualifications and expertise are relevant to the worker’s injury and situation (the independent consultant should be of the same discipline as the treating allied health practitioner wherever possible)
that if a physical assessment is required, the location of the consultant’s rooms is as geographically close to the worker’s home address as possible or accessible within the worker’s travel restrictions
that any special requirements of the worker relating to gender, culture or language are identified and accommodated
that, if a physical assessment is required, the rooms should contain appropriate facilities, including access for people with ambulatory difficulties and accommodate the worker’s specific physical needs
that there is no conflict of interest.

Note: Due to impact of the COVID-19 (Coronavirus) pandemic on access to and delivery of face-to-face consultations, insurers should consider approving telehealth consultations if it is appropriate to do so.

New payment classification codes for telehealth consultations have been applied to the revised Independent Consultant Fees Order.

Making a referral to an independent consultant

Whenever possible the insurer should contact the worker by phone to discuss the need for the independent consultant referral.

When making a referral to an independent consultant, the insurer is to advise the worker and treating allied health practitioner in writing. The table below outlines the information to be included in the written notice to the worker.

Review stage	Written notice to the worker
For stage 1 and 2 reviews (when the worker is not required)	If the independent consultant will not be assessing the worker in-person, the notice to the worker is to include: the name, specialty and qualifications of the independent consultant a copy of the referral letter to the consultant which includes the specific reason for the referral a list, or copies of, the documents provided to the consultant that the treating allied health practitioner will be provided with the report from the assessment.
For stage 3 reviews (when the worker needs to attend an appointment)	If the worker is to be assessed by the independent consultant, they must be given at least 10 working days’ written notice of the appointment, unless a shorter timeframe is agreed by all parties. The written notice is to include: the date, time and location of the appointment (within normal business hours) name, specialty and qualifications of the independent consultant contact details of the consultant’s offices and appropriate travel directions the likely duration of the consultation what to take, eg x-rays, reports of investigations/tests notice to wear comfortable clothing to enable an appropriate consultation that they may have a support person (other than their legal representative) accompany them during the assessment, including for the consultation, however this person cannot participate or interfere in the consultation if they (or their support person) plan to record the consultation, they must inform the consultant prior to the appointment to get agreement that the insurer will meet any reasonable costs incurred by the worker, including wages, travel and accommodation, and how the worker can claim these expenses when the travel incurred will be significant (such as airfares), the insurer is to make the necessary arrangements and pay directly. If the worker is not reasonably able to travel unescorted, this may include expenses for the worker’s escort that the treating allied health practitioner will be provided with the report from the consultation.

Review stage

Written notice to the worker

For stage 1 and 2 reviews (when the worker is not required)

If the independent consultant will not be assessing the worker in-person, the notice to the worker is to include:

the name, specialty and qualifications of the independent consultant
a copy of the referral letter to the consultant which includes the specific reason for the referral
a list, or copies of, the documents provided to the consultant
that the treating allied health practitioner will be provided with the report from the assessment.

For stage 3 reviews (when the worker needs to attend an appointment)

If the worker is to be assessed by the independent consultant, they must be given at least 10 working days’ written notice of the appointment, unless a shorter timeframe is agreed by all parties. The written notice is to include:

the date, time and location of the appointment (within normal business hours)
name, specialty and qualifications of the independent consultant
contact details of the consultant’s offices and appropriate travel directions
the likely duration of the consultation
what to take, eg x-rays, reports of investigations/tests
notice to wear comfortable clothing to enable an appropriate consultation
that they may have a support person (other than their legal representative) accompany them during the assessment, including for the consultation, however this person cannot participate or interfere in the consultation
if they (or their support person) plan to record the consultation, they must inform the consultant prior to the appointment to get agreement
that the insurer will meet any reasonable costs incurred by the worker, including wages, travel and accommodation, and how the worker can claim these expenses
when the travel incurred will be significant (such as airfares), the insurer is to make the necessary arrangements and pay directly. If the worker is not reasonably able to travel unescorted, this may include expenses for the worker’s escort
that the treating allied health practitioner will be provided with the report from the consultation.

Note: The worker’s attendance is voluntary. The insurer should advise the worker of the benefits of attending the consultation (if attendance is required) however failure to attend will not obstruct the worker’s entitlement to recover compensation or weekly benefits.

Communication with the independent consultant

The insurer should provide the independent consultant with adequate and relevant information to support the referral including:

a detailed description of the reason for referral
contact details of the worker and nominated treating doctor and
relevant documentation from the claim file to aid the independent consultant’s understanding of the claim (this should not include a copy of the worker's entire claim file).

After the independent consultant’s report is received

Once the insurer has received the report from the independent consultant, they are to release it to the treating practitioner (if it has not already been provided).

The insurer is to talk to the worker about the action to be taken following receipt of the report. This might mean advising the worker that treatment has been approved, that a dispute notice is being issued, or that there is no further action required.

An independent consultant’s recommendations are not binding but should be taken into consideration by the insurer, as well as other information available at the time.

Working toward best practice
A review by an independent consultant can heighten anxiety in a worker. A telephone call from the insurer advising the worker of the outcome can help alleviate this.

Fees and invoicing

Fees

Independent consultant fees are a claims cost and not a treatment cost. Fees for independent consultant services are set out in the Independent Consultants Fees Order.

The fees order specifies:

the maximum amount payable for medical services carried out for workers compensation claims
the codes providers are to use
what various services include
that workers are not liable for these costs.

Pre-payment for reports or services is not permitted.

Invoices

Invoices must meet SIRA invoicing requirements and must be submitted within 30 calendar days of the examination.

See also Insurer guidance GN 4.3 Invoices and Reimbursements.

Working towards best practice
Insurers should call the practitioner if they have questions regarding an invoice. Errors or queries can often be resolved quickly over the phone - this is beneficial to all parties. If telephone contact is unsuccessful, then an email or letter should be sent seeking clarification. Insurers should attempt to resolve an issue rather than just not pay an invoice. Non-payment of an invoice can be detrimental to the insurer-health practitioner relationship and negatively impact the worker’s recovery.

Working towards best practice

Insurers should call the practitioner if they have questions regarding an invoice.

Errors or queries can often be resolved quickly over the phone - this is beneficial to all parties. If telephone contact is unsuccessful, then an email or letter should be sent seeking clarification.

Insurers should attempt to resolve an issue rather than just not pay an invoice. Non-payment of an invoice can be detrimental to the insurer-health practitioner relationship and negatively impact the worker’s recovery.

GN 6.4 Allied health practitioners

GN 6.6 Referral to an injury management consultant

Related: Legislation and regulations

Related: Guidelines and standards

Related: Insurer guidance