Types and purpose of investigations

Throughout the course of the claim the claims service provider may need to request investigations to gather medical and/or factual information about the claimed injury.

In the first instance, the claims service provider (CSP) will always request the information from the treatment providers since they are best placed to provide input based on their regular reviews and in-depth knowledge of your worker and their injury.

Generally speaking, the evidence supplied by the treatment team (nominated treating doctor, psychologist, psychiatrist and so on) tends to hold more weight than that of an independent one-off assessment.

Whilst some investigations may be necessary on a claim, it's worth considering the effect it may have on your worker and their mental health condition.  Throughout the claim journey the injured worker may be required to repeatedly revisit and retell the events surrounding their injury which may resurface the associated trauma that accompanies their injury.

Where possible, the CSP should be trying to yield the necessary information through less intrusive means that do not exacerbate your worker's mental health symptoms.

On this page

Key takeaways

Factual investigations

Independent Medical Examination (IME)

Injury Management Consultation (IMC)

Independent Psychological Consultation (IPC)

Pharmacy Review

Key takeaways

  • Both factual and medical investigations can be utilised on a mental health claim
  • The three main types of medical investigations include:
    • Independent Medical Examination (IME): used mainly for liability purposes
    • Injury Management Consultation (IMC): used mainly for capacity and return to work enquiries
    • Independent Psychological Consultation (IPC): used to review treatment to ensure the injured worker is receiving the most appropriate treatment for their injury.
  • Whilst investigations can be necessary, the claims service provider needs to consider the cost to the injured workers well-being. Where possible the insurer should try to source the information through less invasive ways to prevent an exacerbation of mental health symptoms.  

    Factual investigations

  • Purpose

    A factual investigation is utilised to objectively and independently determine the facts surrounding an injury or incident.

    This service is typically used to:

    • gather information around an incident where there is unclear or limited information available
    • clarify that the injured worker making a claim meets the legislative definition of a worker (Section 4 of The Workplace Injury Management and Workers Compensation Act 1998).

    A factual investigation can yield the necessary information that can assist the CSP to make soundly based liability decisions.

  • Process

    The investigative process is completed by an independent third-party service provider. In most cases, the investigator will commence interviews to take statements from the worker, any eyewitnesses and/or any relevant supervisors or managers. Both the employer and worker should be afforded the opportunity to nominate witnesses.

    Once the interview is concluded, the investigator will send a draft statement back to the participants to read and sign their respective statements to confirm it accurately reflects the interview. The investigator may also gather any necessary evidence from the respective parties such as policies and procedures and personal records.

    Each of the statements and supporting evidence will be provided to the CSP alongside a comprehensive report. Once the investigation has been completed, your CSP can provide you with a summary of the factual report.

    The worker is able to have a support person present for their interview with the investigator. The support person is there for support only and is not there to contribute to the interview.

  • Benefits

    The factual investigation has the possibility to provide the CSP with the necessary information to make a more robust and soundly based liability decision.

    The factual investigation allows the employer the opportunity to provide their version of events and any supporting document, particularly important for Section 11A of Workers Compensation Act 1987.

  • Potential limitations

    The investigative process could be particularly damaging to individuals who are experiencing mental health symptoms. The investigation requires them to retell their story again, a story that they have already likely told multiple times and that may be triggering for your worker to keep revisiting. CSPs will need to consider the wellbeing of the worker when considering whether a factual investigation is needed, and whether the information can be obtained using a less intrusive method.

    Often in cases where there is interpersonal conflict, the statements will reflect each of the individuals' perception of events and may therefore provide little value when it comes to the CSP making a liability decision, but may however erode the relationship between the worker and employer which has the potential to impact recovery and return to work.

    Independent Medical Examination (IME)

  • Purpose

    CSPs may use this report to make decisions around entitlements, injury management and return to work. The report allows the CSP to gather information or evidence that relates to causation, the circumstances of injury, medical history as well as a professional opinion on diagnosis. 

  • Process

    Before the CSP can proceed to an IME, they need to make reasonable attempts to gain the relevant information from the treatment providers. If unable to do so, the CSP will notify the worker of their rationale for pursuing an IME and offer three different IME options. Once selected, the CSP will schedule the IME for the worker and ensure they have adequate means to get there.

    The assessment will be conducted by a psychiatrist, who will utilise their expertise to review the evidence forwarded by the CSP, assess the worker in a face-to-face (or via telehealth) setting which tends to last one hour, and provide the CSP with a comprehensive report.

    If the initial report received from the IME doctor does not answer all the CSP's questions, or there is some ambiguity within the report, the CSP can request a supplementary report.

    Tip: The CSP is able to ask the IME psychiatrist specific questions that form part of the report – if you have any questions you would like asked, you may wish to notify your CSP.   

  • Benefits

    An IME can assist with information relating to:

    • diagnosis of an injury reported by the worker
    • determining the contribution of work incidents, duties and/or practices to the injury
    • whether the need for treatment results from the worker's injury and is reasonably necessary
    • recommendations and/or need for treatment
    • capacity for pre-injury duties and hours
    • any restrictions the injured worker may have
    • the likelihood of and timeframe for recovery
    • capacity for other work/duties (descriptions of such duties are to be provided to the IME)
    • what past and/or ongoing incapacity results from the injury.
  • Potential limitations

    Whilst it may be beneficial to have a fresh set of eyes to review the worker in an IME appointment, it's worth noting that the weight of evidence does not compare to that of the treatment providers who review the worker frequently, have access to their clinical history and are therefore better placed to understanding the worker from a holistic viewpoint. The IME is based on the worker's self-report on the day and may not truly appreciate all the intricacies of the injury.

    This can be the case if the worker is sent to an IME too early in the claim before the CSP has a chance to gather evidence from treatment providers and factual investigators. Similar to a factual investigation, requesting that the worker is sent to multiple IME assessments may erode the trust and rapport between the worker and the CSP.

    The CSP is unable to provide you with the full IME report due to privacy. They can however provide you a summary of the report with the key findings around capacity timeframes, return to work goals and prognosis.

    Injury Management Consultation (IMC)

  • Purpose

    An IMC can be used on claims to address queries relating to capacity and when there are complex return to work and injury management barriers that can't be resolved via the treatment providers on the claim. For example, when:

    • recovery or return to work goals are confused, when there is no clear direction on the claim in terms of return to work
    • the injury or workplace environment is complex
    • there are communication issues between the worker, the employer and the treating doctor
    • there is a conflict between the treating doctor's recommendations and the workplace requirements
    • there are unexplained changes in work capacity or when the worker is not upgrading at work
    • there is a disagreement about the suitability of work being offered at the workplace.
  • Process

    There are three types of IMCs:

    • Stage 1: involves the IMC Doctor completing a comprehensive file review and providing a report with recommendations to the CSP
    • Stage 2: the CSP sends all the relevant files to the IMC Doctor to review. Following this, the IMC Doctor will have a discussion with the injured worker's doctor to discuss the concerns raised and recommendations to overcome any barriers and move the claim forward
    • Stage 3: involves a file review of the relevant documents, a face-to-face (or telehealth-based) assessment of the injured worker and concludes with a robust discussion between the IMC doctor and the injured worker's doctor to resolve any barriers on the claim.

    Each of the above stages is concluded with the development of a comprehensive report for the CSP with their findings and recommendations.

    For psychological injuries, accredited IMCs that can be used include psychiatric doctors and occupational physicians. The CSP will determine which doctor to refer to based on the complexity of the presenting problem. 

  • Benefits

    IMCs can be useful in instances where there is a breakdown in communication with the NTD. Some doctors may prefer to discuss the claim and its intricacies with a fellow Doctor.

    An IMC may serve as a fresh set of eyes to review the injured worker and may uncover the reasons for the barriers preventing upgrades in functioning or capacity.

    IMCs can also reach out to other treatment providers (such as psychologists) to understand their perception of areas such as capacity, injury management or return to work goals.

  • Potential limitations

    Some NTDs may be reluctant to participate in the IMC process and may not implement the recommendations provided by the IMC doctor.

    Requesting an IMC may erode the injured worker's trust in the claim process. The CSP needs to be mindful of the number of investigations they request the injured worker completes across the life of a claim. Workers may feel the need to keep validating their lived experience which may negatively affect their self-esteem and motivation to return to work.

    Bringing another viewpoint onto the claim may make the injured worker feel disempowered in the process.

    IMC reports can be used in work capacity decisions to determine the injured worker's level of capacity when the NTD is reluctant or unwilling to upgrade capacity despite numerous medical opinions supporting an increase in capacity on the Certificate of Capacity.

    Independent Psychological Consultation (IPC)

  • Purpose

    IPCs can be utilised on psychological claims to provide an impartial peer review of the treatment that is ongoing on the claim. The IPC is a registered psychologist who can review and discuss the current treatment plan with the injured worker's psychologist.

    Areas discussed may include:

    • The modality of treatment and its effectiveness for the injured worker's injury
    • The frequency and duration of treatment and whether this is appropriate and effective
    • Whether the treatment continues to be reasonably necessary
    • Any barriers or psychosocial risks
    • Any return to work concerns.
  • Process

    There are three types of IPC reviews:

    • Stage 1: the IPC psychologist will receive all the necessary file from the CSP, complete a review and provide their recommendations of ongoing treatment
    • Stage 2: a file review is completed, and the IPC psychologist will schedule a discussion with the treating psychologist to discuss all aspects of the treatment plan and prognosis
    • Stage 3: the IPC psychologist completes a file review, an assessment of the injured worker and concludes with a discussion with the treating psychologist.

    Once their review and/or assessment is completed, the IPC psychologist will provide a comprehensive report to the CSP with their findings and recommendations. A copy of the report will also be provided to the treating psychologist for their records.

  • Benefits

    Similar to the other investigations, it can be beneficial to have an independent qualified practitioner provide their findings and recommendations since they're not entrenched in the claim.

    The IPC psychologist may be able to assist the treating psychologist in refining their treatment plan to better suit the injury type and any barriers on the claim.

    Potential limitations

    Even though the IPC psychologist may have a general overview of the injured worker's condition and the current treatment plan, it's unlikely they will know the intricacies as well as the treating psychologist who reviews the injured worker on a frequent basis. The treating psychologist may therefore not follow through with the recommendations set forth in the peer-to-peer discussion. 

    Pharmacy review

  • Purpose

    A pharmacy review may assist in assessing any risk associated with the worker's medications.

    Some examples of when a pharmacy may be appropriate include:

    • a repeat prescription for high-risk medications
    • a combination of high-risk medications (for example, opioids, benzodiazepines, sleep medications and antidepressants)
    • multiple pharmacies supplying the high-risk medications
    • injectable narcotics or medicinal cannabis prescribed
    • high-risk medications used for over two weeks
    • a transition to the GP following discharge from hospital (for example, post-surgery or if discharged with high-risk medications)
    • comorbidities such as psychiatric disorders, cardiovascular disease, respiratory disease, sleep apnoea
    • history of drug dependence or addiction
    • a risk of self-harm.
  • Process

    A medication review can be requested by a CSP to provide an independent assessment of the overall medication prescribed.

    It's conducted by a registered pharmacist or medical advisor with the worker and their doctor.  

  • Benefits

    The review should result in a medication plan informed by evidence and clinical best practice guidelines.

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