Where there is medical treatment only

In some circumstances, an employee may be fit for his or her employment but may be receiving ongoing medical treatment.

Not only do costs easily escalate where they are not monitored, the employee has an expectation that he or she may continue to be provided with unlimited ongoing treatment, where such treatment is not questioned or managed.

In this regard, it is important to assess what is “reasonable for the employee to obtain in the circumstances” (section 16 (1) of the Act refers).

Treatment plans

The introduction of treatment plans ensures the employee is not receiving treatment over an extensive period of time for which there is no apparent benefit, and therefore is not reasonable medical treatment.

A treatment plan is similar to a Return to Work Plan.  It requests that treating doctors set out treatment goals and the number and duration of treatments needed to achieve those goals.

Where an initial review date has not yet been allocated and the employee has not been advised that a treatment plan will be necessary, accounts submitted for payment should be considered in the normal way, with the employee being provided with a letter and Additional Advice to Claimants notice.  A Medical Review Certificateshould also be provided at this time.

Expected

In all cases, prior to the following forms of treatment commencing or being paid:

• physiotherapy and associated techniques, such as Feldenkrais;

• massage;

• chiropractic treatment; and

• other accepted therapeutic medical treatments

a clear outlined plan of treatment from the treating doctor will be required.  The employee is advised of this obligation as part of the Additional Advice to Claimants information notice.

Treating doctors must be sent the Medical Review Certificate for completion.  It outlines:

• who will be providing the course of treatment;

• how the treatment relates back to the compensable condition;

• the number of treatments required or duration of treatment; and

• the expected benefits of the nominated treatment.

Generally, any later costs for the same treatment falling outside the treatment plan will not be covered.

Where a treatment plan fails to reach a satisfactory outcome (that is, where treatment has not been of therapeutic value for the employee), further extensions of treatment cannot normally be supported.

The number of treatments and extent of treatments required:

will provide a clear time frame where ongoing medical treatment only is being claimed.  Payment to the doctor for such a service will equate with reasonable costs paid for completion of medical reports.

A letter which clearly outlines the extent of treatment that has been accepted, should then be issued to the employee.

It is essential that treatment plan information be entered onto PRACSYS to ensure that payment is made only for those treatments identified by the treating doctor.  Both the nature and duration of treatment must be included as a Claim Comment in the 'B'enefit category, against the 'ALT' (payment alert) code.

If this procedure is not completed, use of treatment plans to monitor the extent and nature of treatments is negated.

Expected liability less than 6 weeks

Where benefits on a claim are not expected to exceed 6 weeks, therapeutic service providers

may complete an initial treatment plan in lieu of the treating doctor.  However, in all cases, the service provider should provide a copy of the plan to the doctor for his or her records.

Where an extension to the initial plan is required, this must then be provided by the treating doctor, as the doctor is best placed to holistically monitor the employee's condition, particularly in relation to rehabilitation and other more broad based needs.

Diaries

Review of treatment plans should be undertaken by the claims manager at least a week prior to completion of the plan.  This will ensure that there are no discrepancies between what has been paid and what has been agreed.

To ensure the review is undertaken, it will be necessary to create a diary when plan details are initially received, which will be generated in the week prior to finalisation of treatment.

Time taken during work hours to undergo treatment

While section 41 Rehabilitation guidelines ensure that, where possible, employees on a graduated return to work receive medical treatment outside working hours, it is also Comcare policy that employees working full time who undergo treatment, where practicable, do so outside normal core hours (Operational Advice No 97/004 refers).

In this regard, employees are advised on the Additional Advice to Claimant information notice that:

It is then the employee's responsibility to liaise with his or her employer on agreed arrangements to undertake treatment.