Actions that flow from investigations: How does the claims service provider use this information?

The investigations used on claims can assist claims service providers to make sound decisions on liability, treatment and provide updated clinical opinions on your worker's injury and recovery planning.

The key points the claims service provider is seeking from the investigations are:

  • Evidence around causation of injury: how did the injury occur and what's the relationship to the workplace?
  • Confirmation of the diagnosis for the injury and the proposed treatment plan to facilitate recovery and return to work
  • Information around medical history: is there anything in the injured worker's medical history that may contribute to delayed recovery or an exacerbation of symptoms?
  • Whether the requested treatment is considered reasonably necessary: what other treatments have been trialled so far, how effective were they and what is the clinical reasoning for this new treatment request?
  • Details around the barriers causing delayed recovery and return to work.

Once the claims service provider has received a report from an investigation they will:

  • Review the information provided to determine whether it is consistent with that already on the claim. The report may be reviewed by the case manager as well as specialists within the claims service provider, such as a technical specialist, legal specialist or an injury management specialist
  • Ensure the information provided by the assessing doctor, psychiatrist or psychologist addresses each of the questions the claims service provider may have. If there is any ambiguity within the report, the claims service provider may request that a supplementary report is provided to address a specific question
  • Send the medical report to the treatment team to afford them an opportunity to review the report and provide their opinion
  • Review the information within the report to determine whether the workers compensation legislation has been satisfied
  • Review the information within the report to determine whether the requested treatment is considered reasonably necessary in the opinion of the independent consultant who assessed the injured worker.
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