Q-COMP - Working Together

Content on this page:

Definitions
Establishing a Foundation for Effective Communication
Methods of Communication
Medical Report Requests and Responses
Payment for Reports

Effective Communication between Medical Practitioners and Insurers

This page outlines key elements for effective communication between Queensland's workers' compensation insurers and the medical profession. It provides practical advice to medical practitioners and insurers and to assist in the exchange of medical information necessary to manage workers' compensation claims under the Workers' Compensation and Rehabilitation Act 2003 (the Act), including processes associated with determining liability, ongoing compensation and injury management.

Definitions

Insurer - Reference to an insurer in this document refers to WorkCover Queensland or a self-insurer.

WorkCover Queensland is the largest insurer in Queensland and handles approximately 85% of all claims. In Queensland, every employer, unless licensed as a self-insurer, must have a workers' compensation policy with WorkCover Queensland. Employers may be licensed by Q-COMP to become self-insurers if they meet set criteria and follow specific procedures. A self-insured employer takes on all liabilities for any work-related injuries or diseases for their workers. The Act applies to all of these insurers.

Determination - A worker will receive workers' compensation benefits when the insurer accepts the worker's application for compensation. The process for determining whether an application for compensation is to be accepted or declined under the Act is sometimes referred to as determination of liability.

Questions the insurer must answer in order to determine liability include:

Is the person a 'worker' (as defined under the Act)?
Has the worker suffered an 'injury' (as defined under the Act)?
Did the injury arise out of or in the course of employment (as defined under the Act)?
Is employment a significant contributing factor to the 'injury'?
Do any of the exclusion provisions under the Act apply?

Work capacity - Work capacity is decided by the worker's treating medical practitioner based on the worker's medical status and is documented on the medical certificate. Total incapacity for work means that, due to the severity of their injury or disease, the worker is not only unable to work in the pre-injury job, but is unable to work in any capacity. Partial incapacity for work means that the worker is able to participate in some work tasks that are appropriate to their functional state.

Workplace rehabilitation - Under the Act, employers, workers and insurers are obliged to participate in rehabilitation. These obligations include offering suitable duties and graduated return to work programs as appropriate. Treating medical practitioner approval is required for these rehabilitation programs.

Stable and stationary - A condition is referred to as stable and stationary when the condition is not likely to improve with further medical or surgical treatment over the next 12 months. This suggests that the condition has reached maximum medical improvement.

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Establishing a Foundation for Effective Communication

Medical Practitioner
The medical practitioner should indicate their preferred method for communication on the medical certificate (in the case of treating medical practitioners), or during the first contact with the insurer in all other cases.

The medical practitioner should indicate the times when they are most easily contacted by the preferred method for communication provided to the insurer. For example, book telephone conferences between 12 and 2pm.

Insurer
When an insurer initiates communication with a medical practitioner, it is important that they clearly indicate the purpose of the communication. For example:

establishing initial contact and providing contact details, including those of the claim/case manager overseeing the claim;
establishing medical evidence relating to liability;
discussing progress of the claim;
clarify medical treatment/rehabilitation options;
advising that payment is available for services under the relevant Medical Table of Costs; or providing documentary evidence for later reference.

The insurer should make this initial contact with the worker's treating medical practitioner(s) as soon as possible after receiving the worker's claim for compensation.

Where not indicated on the medical certificate, the insurer should request the treating medical practitioner's preferred method for future or ongoing contact and use this preferred method in future contact.

The insurer should inform the treating medical practitioner of the liability status of the claim in their communication.

The insurer should offer to supply a copy of the documentation for the current claim that provides consent for medical information to be disclosed by the treating medical practitioner.

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Methods of Communication

These include:

Telephone contact - initiated by a treating medical practitioner, employer, rehabilitation provider or insurer for planning rehabilitation for a specific worker.
Case conference - to plan, implement, manage or review a rehabilitation plan or treatment options. Must result in an agreed plan with strict timeframes and be evaluated for outcome on completion.
Completed form - provided by the insurer, the form is completed by the medical practitioner giving basic information for the management of the claim.
Phone/fax report - the insurer prearranges a phone interview with a medical practitioner and documents the response. The medical practitioner signs a faxed transcript of their response.
Progress report - written in response to a request for specific information at a specific stage of the claim and answers questions relevant for proactive case management, eg. information about a specific line of treatment or progress for return to work. Only information that is subsequent to previous reports should be provided.
Comprehensive clinical report - written by the treating medical practitioner in response to an insurer's request for specific information. It may include clinical findings, summing up and an opinion helpful to the insurer. The insurer may ask questions relating to the phases of the claim, eg. establishment, ongoing management and return to work.The type of information sought may include a statement of attendance, history, diagnosis, investigations, prognosis, clarification of treatment, relationship of condition to employment and capacity for work.
Independent comprehensive clinical report - written when the insurer requests an independent examination and report. It should include a medical summary of the case, the clinical findings and a medical opinion on aspects of the case, as requested by the insurer. The insurer may ask questions relating to phases of the claim, eg. establishment, ongoing management and return to work. The type of information sought may include a statement of attendance, history, diagnosis, investigations, prognosis, clarification of treatment and return to work goals. The specialist should give their opinion outlining the nature of the injury, capacity for work and advice on the future management of the case.

Each of these methods of communication are payable under the Medical Table of Costs Supplementary Schedule (see also Payment for Reports).

Medical Practitioner
The medical practitioner may not wish to provide a response to the questions using the method indicated by the insurer. In this case, they should advise the insurer of their reasons and preferred method for response to see if it is suitable in the circumstances.

Insurer
Consideration should be given to use of the simplest method of communication to resolve the particular claim or case management issue.

The insurer may:

request information and/or a medical opinion from the medical practitioner in a communication format appropriate to resolving a claim or case management issue. This format may depend on relevant evidentiary considerations; or
present questions to the medical practitioner and ask for a response within 10 days from when the report request is received.

In some instances, there may be flexibility in the format for the response provided by the medical practitioner - for example a case conference or phone/fax report may be acceptable. For evidentiary reasons, there will be some circumstances however where the insurer will require the medical practitioner to provide a formal written medical report.

In the case of verbal communication (telephone contact, case conference, phone/fax report) the insurer should schedule an appointment with the medical practitioner. The medical practitioner's practice staff should be notified in advance of the appointment, the type of information that will be discussed and availability of payment.

Phone/Fax Reports

Medical Practitioner
During the appointment, the medical practitioner should:

identify what documents are relevant to the formation of their opinion;
identify facts or assumed facts which form the basis of their opinion;
state their opinion;
advise if the opinion is subject to any qualifications; and
provide any other comments they consider relevant.

In the case of a phone/fax report, the medical practitioner should amend the documents received if they do not consider that the document is an accurate reflection of the discussions undertaken. The medical practitioner is required to sign the phone/fax report (amended if necessary) and return the document to the insurer promptly.

Insurer
In the case of a phone/fax report (developed by the insurer following a telephone discussion), it is recommended the insurer complete the following steps:

Prior to the appointment:

confirm the date, time and expected duration of the appointment in writing;
advise of the purpose of the appointment, the process and what will happen following the discussion;
advise the medical practitioner to have the following available during the appointment: clinical notes;
dates claimant attended; and
any relevant medical documents used, for example, an x-ray; and
offer the medical practitioner the option of providing a "comprehensive clinical report" where circumstances warrant, for example, where the claim concerns complex and/or multiple medical issues/injuries.

During the appointment:

explain the purpose of the appointment;
confirm the treating medical practitioner has a copy of the claimant's clinical notes; and
confirm the dates the claimant attended the medical practitioner in relation to the relevant injury.

After the appointment:

phone/fax report is prepared by the insurer and sent to the medical practitioner outlining the process for making amendments and finalisation; and
reiterate the process for the medical practitioner to return the signed document to the insurer (with amendments if necessary). This process is complete when the medical practitioner provides the phone/fax report to the insurer.

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Medical Report Requests and Responses

The purpose of a medical report is to assist in the timely management of the injury, rehabilitation and return to work and, where required, to provide clarification and direction on:

diagnosis of injury;
the relationship of the injury to employment;
ongoing incapacity and the relationship of this to the compensable injury; and
rehabilitation and return to work.

Insurer
In the request, the insurer should state the purpose for the report. For example the report may be to:

ascertain or better understand the diagnosis/prognosis of the injury;
clarify the relationship of the injury to employment, as stated by the worker;
establish ongoing incapacity for work;
consider treatment/rehabilitation options;
consider return to work options;
finalise the claim; or
assess permanent impairment.

It is important that the questions asked in the request can be clearly understood by the medical practitioner. It is ideal for medical input to be sought by the insurer from a medical advisor to ensure that all questions asked in the individual report request are medically relevant and to ensure that the purpose and type of report request is appropriate.

Report Type

Medical Practitioner
The medical practitioner should provide the medical information requested by the insurer within 10 days of the request (as per s86 of the Act). Written correspondence should be clearly dated. Where the medical practitioner is unsure of the reason for the report request, the purpose for which the information will be used or any other aspect of the request, they should contact the insurer to discuss the issues of concern. The medical practitioner should charge as per the relevant item number for the type of report they are providing in accordance with the Medical Table of Costs Supplementary Schedule. If a report needs to be more detailed than that requested or a further examination of the worker is required to answer the questions, the medical practitioner should contact the insurer to discuss the issues.

Insurer
The report request should state the type of medical report that the insurer requires, taking into consideration the stage of the claim, for example:

progress report;
comprehensive clinical report;
independent medical opinion; or
assessment of permanent impairment.

The relevant item number from the Medical Table of Costs Supplementary Schedule and corresponding fee amount should be stated in the report request together with a statement that payment is dependant upon the type of report provided to the insurer. Where separate and specific responses to the individual questions provided in the request are required by the insurer, this should be clearly stated in the request.

Transmission of a Medical Report

Medical practitioners should continue to send medical reports in accordance with their current business procedure, ie. by post and/or fax. For privacy and evidentiary reasons it is recommended that medical reports are not transmitted by email unless the insurer has an adequate system in place to:

ensure that confidentiality of the email is maintained via encryption software or other secure transmission;
identify the medical practitioner who provided the medical report;
ensure the medical report is authentic, ie. that the communication is genuine and originated from its apparent source; and
ensure the medical report cannot be altered en route, or once it has been received.

Structure of a Formal Written Report Request

Medical Practitioner
Where requested by the insurer, the medical practitioner should provide specific responses to the individual questions in the report request. If the medical practitioner is unable to answer the questions requested by the insurer they should advise the insurer accordingly. Medical practitioners should provide a response within 10 days after receiving the insurer's request to do so.

Insurer
The structure of the report request may include:

type of report required, item number and remuneration for the report being requested;
claim details;
liability status;
employment details;
the reason for the report request;
case to date summary;
information from the workplace about the type of duties and tasks the worker performs such as a task list from the workplace, diagrams and photographs;
questions relevant to the current phase of the claim only;
an attached index of existing relevant reports, documents or investigations accompanying the report request; and copies of relevant claim documents*.

* Only attach copies of documents relevant to the questions asked in the report request.

The insurer should confine their report request to questions that are medically and directly relevant to the current stage of the claim and for proactive case management. Consideration should be given to past report requests made on the claim and whether the information has been previously supplied. Reference should be made in the report request to any past reports provided by the medical practitioner in relation to the current claim.

Independent Examination and Report Requests and Associated Processes

Medical Practitioner
Completion of an independent medical examination and report preparation should comply with relevant practice and ethical guidelines.

Independent medical practitioners should ensure that the report is provided to the insurer within 10 days after the examination. Written correspondence should be clearly dated and also state the date of examination(s).

Should the treating medical practitioner wish to be informed of the findings and recommendations of an independent examination they should request this information by contacting the relevant insurer's claim or case manager.

Insurer
When the insurer makes a referral for an independent examination and report, contact should be made by the insurer with the treating medical practitioner. In ordinary circumstances, the purpose of this contact is to notify the treating medical practitioner of the independent medical examination and reasons for referral. Contact may be made by the most appropriate, established or preferred method for communication between the two parties given the circumstances concerning the claim.

The insurer should note in written report requests, the date by which their written response is required and relevant provisions for payment from the Medical Table of Costs Supplementary Schedule.

In ordinary circumstances, other than for assessment of permanent impairment, the insurer should first consider requesting medical information from the worker's treating medical practitioner prior to requesting the medical information from an independent medical practitioner.

The insurer should inform the treating medical practitioner of the findings and recommendations of the independent examination from the report provided.

Requests for Permanent Impairment Assessment Reports

The Medical Practitioner Guidelines for the Assessment of Permanent Impairment document and a sample report format is found on this CD.

Medical Practitioner
The medical practitioner must use the methodology for the assessment of permanent impairment described by the American Medical Association Guides for the Evaluation of Permanent Impairment 4th Edition (AMA Guides 4th Edition) and the Table of Injuries Schedule 2 under the Workers' Compensation and Rehabilitation Regulation 2003 (the Regulation).

The response format should be in an endorsed acceptable format available from Q-COMP or provided by the insurer.

Insurer
Reports on assessment of permanent impairment should be requested to be provided by the medical practitioner in a separate report, and must state that the insurer requires the methodology for the assessment to be that described as per the AMA Guides 4th Edition and the Table of Injuries Schedule 2. The insurer should include a copy of the Medical Practitioner Guidelines for the Assessment of Permanent Impairment with every request. Sample PI Report

The insurer should notify the medical practitioner in the report request that payment for assessment of permanent impairment will be made in accordance with the Medical Table of Costs Supplementary Schedule.

There is a separate payment for the consultation as opposed to the provision of the report.

Requests for Elective and Non-elective Procedures

Medical Practitioner
To facilitate this process the medical practitioner should provide a written request for the medical procedure to the insurer. The request should include the claimant's details, diagnosis, details of the procedure, purpose of the procedure, the relevant item numbers, length of hospitalisation and the costs of any implants or medical consumables to be used in the procedure. Following the procedure, the medical practitioner should provide a copy of their operative notes and post-procedural report to the insurer.

Insurer
Where approval for a procedure has been requested by a medical practitioner, the insurer should request from the medical practitioner a written proposal for the procedure. The proposal should include the claimant's details, diagnosis, details of the procedure, purpose of the procedure, the relevant item numbers, length of hospitalisation and costs of any implants or medical consumables to be used in the procedure.

Following the procedure (including non-elective procedures), the insurer should request a copy of the medical practitioner's operative notes as an inclusion to the medical practitioner's post procedural report if one has not been provided.

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Payment for Reports

Medical Practitioner
The medical practitioner may charge the insurer under the relevant item number of the Medical Table of Costs Supplementary Schedule for the type of report provided to the insurer.

Please note: Reduced fees are payable by insurers if reports are not received within 10 days of the request.

Insurer
Payment for reports falls under the Medical Table of Costs Supplementary Schedule. This states the type and remuneration for the reports requested; the Medical Table of Costs Supplementary Schedule is available at www.qcomp.com.au/medicalservices. An insurer should pay for a report that they have requested. Reduced fee levels are payable for reports received after 10 days.

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