By reviewing case information, the MSP medical specialists can make treatment and medical causation recommendations quickly, in an average of five days compared to six weeks before the commencement of the panel.
For an employer and worker this means faster treatment approval for required interventions and therefore anticipated faster return to work.
The MSP process
1. Case manager refers a claim to the MSP
If a case manager has questions about a medical aspect of a claim, they’ll refer it to the MSP, clearly articulating the current medical concerns that the MSP Specialist can assist with.
2. MSP specialist reviews the claim
Our MSP specialists review case information and talk to stakeholders including workers, employers and treatment providers, as appropriate, to make their recommendations.
MSP specialists will only consider the questions asked in the referral of the claim, they will not review other non-medical aspects of the claim.
3. MSP provides their recommendation to the case manager
Once the MSP specialist completes their review they will provide their recommendation to the case manager.
Once they receive the MSP recommendation, the case manager should apply the legislation, and the claims management decision making framework, together with the MSP recommendation, to make a decision on the claim.
The case manager will explain the MSP’s recommendation and their final decision to stakeholders.
When is a claim referred to the MSP for review?
It is expected that a claim will be referred to the MSP when a case manager/injury management specialist cannot resolve the medical aspects on a claim in relation to:
For cases where there are questions around whether treatment requests are medically appropriate.
Medical causation review*
For cases where there are questions, from a medical perspective only, associated with the following in connection with a claim:
- diagnosis of the injury reported by the worker, including the mechanism of injury
- determining the contribution of work incidents, duties and/or practices to the injury
- whether the worker’s injury has resolved
- whether the injury is an aggravation or recurrence of injury
- opinion on secondary conditions
- whether any proportion of the worker’s injury is due to any previous injury or pre-existing condition or abnormality.
*Treatment and medical causation may also be reviewed together.
Independent Medical Examination (IME) report review
For cases where clarification regarding an aspect of an IME report is sought, or where the case manager believes a supplementary IME Report may be required.
Medical Strategy review
For cases where the case manager is unsure how to manage a medical aspect of a claim, the MSP can review the relevant medical information and provide potential strategies and options to assist the worker’s progress. Medication review For cases where a review of medication is required, the MSP can assist with the following:
- discussion of medication combinations/dosages and alternative options with the treating doctor
- obtaining a list of injury related medications
- clarifying the purpose of particular medications.
Issues out of scope for the MSP
The MSP is not able to make recommendations on the following:
- Capacity for work
- Whole Person Impairment (WPI)
- dental treatment requests
- for psychological claims, the application of Section11A of the Workers Compensation Act 1987 on a claim must be resolved before it can be referred to the MSP for a medical causation review.
In these instances, a case manager may require a worker to attend an IME or gather further information to make their decision.
How will I know if a claim has been referred to the MSP?
The case manager will communicate the initiation of an MSP referral to the worker, employer, and other relevant stakeholders. They will also ask if there is any information the employer would like included for consideration by the MSP specialist who reviews the referral.
The case manager will also ask the employer if they would like to be contacted by the MSP specialist and if so, when in the referral process they would like contact. The MSP will contact the employer when requested. The MSP specialist may contact the employer if they believe this is integral to making the right recommendation.
There are limited circumstances when the worker and/or employer is not informed the claim is being referred to the MSP. For example, if the worker is no longer employed by the organisation or informing the worker of the MSP referral is likely to cause undue distress.
What information does the MSP consider when making recommendations?
The MSP specialists review and consider relevant claim information available.
This could include:
- Certificates of Capacity (initial and current)
- treatment request/s
- recent medical and/or provider reports relating to treatment, medical causation etc
- medical investigation reports ·
- independent Medical Examination/Injury Management Consultant/Independent Consultant reports
- factual investigation documents
- surveillance reports
- rehabilitation reports
- previous/current position descriptions
- claim forms.
MSP specialists may contact workers by phone as well as a worker’s nominated treating doctor and other health professionals involved in their care. The purpose of this contact is to clarify information on the claim and gain further insights relevant to the questions asked in the MSP referral.
The MSP will also contact a worker’s employer when the referral states that this contact is required.
Employers can also provide any additional relevant information to their case manager for the MSP to review.
The MSP does not conduct physical examinations of workers.
What types of recommendations does the MSP provide?
The MSP considers each claim individually and recommendations are made on the facts of the claim based on what is appropriate for the worker and their specific situation. The types of recommendations the MSP may make are:
Support treatment or medical causation
An MSP recommendation may be to support the approval of medical investigations, health interventions, or support medical causation. A recommendation to support treatment or medical causation is made when all information on file, and conversations with stakeholders are consistent and provide sufficient detail for the MSP to determine that the treatment request is appropriate for the worker or that medical causation exists.
New treatment pathway provided
The MSP may recommendation a new pathway, such as alternative treatment, after discussing and obtaining consensus with the worker and other relevant stakeholders (including the nominated treating doctor – usually a GP – and case manager).
Refer to IME
In some cases, the MSP recommends the claim be referred for an IME.
Recommendations to refer a case to an IME occur when the available medical information is inadequate, unavailable or inconsistent.
If this recommendation is provided, the MSP specialist will, in consultation with the case manager, identify the IME specialty type and propose a clinical summary and specific, objective and relevant questions to be answered by the IME.
Medical strategy provided
In cases where the MSP provides further medical direction and strategies to the case manager to assist in progressing the claim.
Medication review provided
The MSP provides guidance and information to case managers regarding the medication a worker is receiving for the work-related condition.
What information does the MSP provide to stakeholders?
As the MSP is a support service to provide medical recommendations to case managers, we do not write reports. The recommendation is sent back on an internal form to the case manager, and in most cases the MSP specialist will also call the case manager to explain the reasons for their recommendation. If a physical review of the worker is required along with a report, the claim will be referred by the MSP to an IME.
The MSP contacts employers when case managers advise that contact is required, in addition if this is not requested but the MSP specialist feels a discussion with the employer around medical concerns would be beneficial, they will make contact if the details have been provided.
The case manager will be able to provide you with details of the MSP recommendation in a summary form or by phone.
What should I do if I have questions or concerns about an MSP recommendation?
If you have concerns or questions about the MSP recommendation you can speak to your case manager for more information. Case managers can liaise with the MSP as required.
How long does it take for the MSP to review a claim?
The MSP has a target of no more than five days to review claims once a completed referral is received.
If an incomplete referral is received, the MSP will be unable to commence a review until all information is provided and the referral is completed by the case manager.
Does a case manager have to agree with the MSP recommendation?
Case managers must give due regard (meaning proper and active consideration) to the MSP’s recommendations.
Where case managers accept the MSP recommendation, it should be implemented, and it is expected that implementation will commence within 24 hours of the recommendation being received.
In circumstances where recommendations are not accepted:
- The case manager must file note the reasons for this, including how they have given due regard to the MSP’s recommendations.
- The MSP Liaison must notify the MSP Operations Manager of their rationale as to why the MSP recommendation will not be implemented, in writing within one business day of the MSP recommendations being received by the Case Manager.
- The case manager will notify the stakeholders of the MSP recommendation and their subsequent decision making to progress the claim.
Can I ask for a claim to be referred to the MSP?
Yes, workers, employers and medical professionals can all ask the case manager to refer a claim to the MSP if they feel it will benefit the claims process and outcome from a medical perspective.
The case manager will follow the standard referral process in these cases, including advising which stakeholders should be contacted by the MSP as they review the claim.
Can a claim be referred to the MSP more than once?
Yes, a claim can be re-referred to the MSP. As a worker’s treatment progresses, new treatments could be requested, questions around ongoing medical causation could be raised or an additional body part may be added to the claim. In these instances, a re-referral may need to be submitted to the MSP, even if the MSP reviewed the claim at an earlier stage.
Which specialists are on the MSP?
There are 11 MSP specialists – three psychiatrists and eight occupational and environmental physicians (two of whom are also dual qualified as general practitioners).
icare requires that all MSP specialists work part-time at icare and maintain clinical roles externally – current clinical practice is a requirement to ensure recommendations are based on latest best practice.
Do MSP services impact premiums?
No, the MSP review of claims and recommendations are not premium impacting.
While MSP reviews and recommendations will be invoiced to the claim, this is for recording and tracking purposes only. These charges are not included when premiums are calculated.