Compensable Schemes

Compensable Schemes: Workers Compensation & CTP

Overview

  • Compensable schemes include Workers Compensation and Compulsory Third Party (CTP).
  • Injuries in compensable settings have a higher chance of poor outcomes than in non-compensable settings.
  • Successful recovery and return to work (RTW) require collaboration among regulators/insurers, case managers, employers, and healthcare providers.

It Pays to Care - Principles for Healthy Injury Insurance Schemes

  • Leadership: Promote a culture of positive psychosocial influence.
  • Collaboration: Empower trust and stakeholder engagement.
  • Fairness: Ensure equitable, transparent decisions.
  • Prioritise Workers: Focus on worker health via evidence-based interventions.
  • Responsiveness: Implement proactive and supportive case management.
  • Communication: Maintain clear and consistent communication.
  • Long-Term Thinking: Prioritise scheme sustainability and workforce development.

Psychosocial Risks in Return To Work (RTW)

  • High psychosocial risk leads to poor health outcomes and increased time off work.
  • A study showed a 4% reduction in RTW chance for every 1-point increase in psychosocial risk (out of 100).
  • 38% of injured workers with musculoskeletal claims have moderate to severe psychological distress, compared to ~11% in the general population.
  • Workers with high psychosocial risk have approximately three times as many days off work.
  • Strategies to mitigate psychosocial risks:
    • Proactive Identification: Use early screening tools.
    • Enhanced Collaboration: Foster collaboration among stakeholders.
    • Empowering Systems: Establish structured management of psychosocial risks.

Workers Compensation (NSW)

  • The NSW Workers Compensation System supports individuals injured at work.
  • Insurers:
    • icare: Provides insurance and care services.
    • Self-Insurers: Employers manage their own claims (e.g., Aldi Stores, NSW Trains).
    • Specialised Insurers: Licensed by SIRA for specific industries (e.g., Coal Mines Insurance).
  • Nominal Insurer Agents (icare):
    • Most employers obtain insurance through icare, which contracts agents to manage claims.
    • Examples: EML, Allianz, QBE.

Timeline of a Workers Comp Claim

  • Initial notification to agent.
  • GP must complete initial Certificate of Capacity (COC) and report incident.
  • Insurer determines liability (within 21 days), providing provisional funds in the meantime.
  • Treatment is provided, with approval for AHTR (Allied Health Treatment Request) within 21 days.
  • Recovery at work is promoted, providing the injured worker and employer with a PIDs (plan).

Entitlements: Workers Compensation

  • Medical, hospital, and rehabilitation expenses.
  • Weekly payments (income support).
  • Permanent impairment compensation.
  • Return to work support, domestic assistance, property damage, and death benefits.

Compulsory Third Party (CTP)

  • CTP (Green Slip) is mandatory for all registered vehicles in NSW.
  • Coverage for injuries sustained as drivers, passengers, pedestrians, cyclists, etc.
  • Covers medical expenses, loss of income, and vocational assistance for physical and psychological injuries.
  • Insurers: Allianz, NRMA, Youi, regulated by SIRA.

Timeline of a CTP Claim - Basics

  • Accident/injury notification.
  • Claim lodged with the CTP insurer of the at-fault vehicle within 28 days for full income support, but no later than 3 months.
  • Initial hospital and ambulance costs are covered.
  • Claim processed within 4 weeks.
  • Reasonable and necessary treatment provided.
  • Support graded recovery to work and ADLs (Activities of daily living).

Threshold vs. Non-Threshold Injuries: CTP

  • Threshold (Minor) Injuries:
    • Definition: Soft tissue or mild psychological injuries (e.g., whiplash, sprains).
    • Entitlements: Up to 52 weeks of medical treatment, weekly income support, and vocational help. No common law claims.
  • Non-Threshold (Non-Minor) Injuries:
    • Definition: Permanent or severe physical/psychological injuries (e.g., fractures, PTSD).
    • Entitlements: Longer-term treatment, weekly payments, and pursuit of common law damages.

Stakeholders in Return to Work

  • Collaboration and cooperation are essential for a thriving RTW ecosystem.
  • Key stakeholders: Injured Worker/Patient/Claimant, GP/NTD, Allied Health Professional, Case Manager, Employer, Rehab Consultant, Insurer/ Regulator.
  • Each stakeholder has a crucial role in delivering fair and effective work injury management.
  • Injured Worker/ Patient/ Client/ Claimant
    • Report Injury Promptly
    • Seek Medical Attention
    • Actively Participate in Recovery
    • Communicate Regularly
    • Comply with Legal Obligations
  • GP/NTD
    • Responsible for initial assessment/ diagnosis
    • Support for patient throughout recovery
    • Arrange and refer to suitable treatment
    • Determine capacity for work
    • Injured workers are 3x more likely to RTW if given a RTW date by their Dr!
  • Allied Health Professional
    • Provide reasonable and necessary treatment in line with ‘Clinical Framework for the Delivery of Health Services’
  • Case Manager
    • Ensures communication between healthcare providers.
    • Organises medical and rehabilitation services.
    • Reviews and processes injury claims.
    • Ensures the worker receives timely compensation and benefits.
    • GOAL = GET THE INJURED WORKER BACK TO WORK IN A COST EFFECTIVE AND TIME EFFICIENT WAY
  • Employer
    • Provide a safe environment for return to work
    • Aim to maintain contact and support patient back into work environment
    • Provide suitable duties where possible
    • An employer can not terminate work within 6 months of a person becoming unfit for work
    • The workplace provides the most cost-effective opportunity to lessen work disability
  • NTS
    • Treatment recommendations (surgery, injections, medication, conservative approach)
    • Timeframe recommendations
    • Confirm RTW goal
  • Rehab Consultant
    • Planning & Coordination
    • Stakeholder Communication
    • Development of Recover At Work Plans
      • GUIDING PRINCIPLES
        • WORK IS GENERALLY GOOD FOR US
        • LONG TERM ABSENCE IF HARMFUL
        • EARLY RETURN = EARLY RECOVERY
        • WORK IS THERAPEUTIC

Health Benefits of Good Work

  • Being at work is generally good for your health and wellbeing.
  • Being away from work can slow down your recovery from injury.
  • Easing back into the job can help you get better sooner.

Recover at Work Plans

  • A structured, written plan outlining how an injured worker will safely return to work—gradually and with appropriate duties.
  • Supports recovery through meaningful activity, sets clear goals, and ensures alignment between all parties.
  • Work duties can be offered in the same job (reduced hours) , different job altogether, work at the same or different place

Influencing Patient's Perception of RTW

  • Identify barriers (physical, psychological, workplace) and work together to address them
  • Foster a belief that recovery is possible and work can be a part of the solution.
  • Highlight the benefits of returning to work - structure, purpose, income, connection.
  • Create a clear, manageable RTW plan with step-by-step goals and timelines.
  • Using a guide such as the HORSE builds trust, reduces fear, and helps clients engage in rehab and return to meaningful activity sooner.

Certificate of Capacity

  • A certificate completed by the treating medical practitioner.

Key Takeaways for EPs

  • Understanding the system makes you more effective and confident.
  • Improves client outcomes and insurer relationships.
  • Sets you apart in a field where understanding the system is crucial.