Some of the issues raised by the Victorian Ombudsman are dealt with in the NSW fee schedule such as definitions of complexity. i continue to argue that the WorkSafe view that any medico can do IME work with out training in assessment and report writing is fatally flawed. Note that there is an induction process but it assumes competencies in the areas I have mentioned. Also not the fees in NSW and those in Victoria even with a 25% increase in April 2019 (because they could not attract enough psychiatrists to do the work?)
The Report of the Victorian Ombudsman-Worksafe 2: Follow-Up Investigation into the Management of Complex Workers Compensation Claims
This report is a follow-up investigation to the initial report published in 2016 and the further report in 2019. In particular I have focussed on the section entitled:
Oversight of the IME System (page 189)
This section discusses appointments of IMEs, feedback regarding the new selection criteria, quality assurance issues and changes since the 2016 investigation.
I think there is a fundamental lack of understanding by WorkSafe that the skill set required of an IME is additional to the generic skills of medical specialists and general practitioners. The assumption is that without additional training IMEs can perform the tasks required leads to inadequate reports and an apparent vacuum with regard to measures to improve quality.
The assumption made by WorkSafe is that their selection criteria, induction and service standards are adequate. These include:
The successful applicants must then participate in an induction process that includes:
The IME service standards state that reports should:
An adequate course of training should equip prospective IMEs with the skill set to do the work required. Such a training program should include a didactic course, mentoring and the opportunity for further training as required.
The importance of training is both with regard to new IMEs being able to function effectively in that role from the beginning but it also provides an avenue by which IMEs whose reports are thought to be problematic can be provided with further assistance to improve their level of skills.
Many prospective IMEs accept that such a training program would need to be self-funded.
IME work is a subspecialty that would involve generic training and training for particular craft groups..
The RACS does provide IME training but no other medical colleges do so. Most IMEs have to learn” on the job”.
Effective IME raining should include:
No IMEs are required to be trained in doing assessments yet all IMEs are required to attend impairment assessment training. This is a case of the tail wagging the dog.
These comments should be considered in the context of my assessment of Recommendations 13 and 14:
Recommendation 13
Provide different time allocations for independent medical examinations of injured workers with “complex claims” and remunerate IMEs for these accordingly.
The definition of a complex claim according to this report is:
A claim involving workers who are unable to work long-term and/or require long-term medical treatment.
Many of these involve chronic back problems and/or mental health issues. Psychiatrist IMEs assessed many claimants with the issues described in this definition.
At the moment Item PCT100 is the only item available for a first examination and report by a psychiatrist. This is the standard fee for all reports no matter the degree of complexity. The AMA anticipates a new fee schedule from WorkSafe. However the current fee schedule contains the following instruction:
Loadings additional to examination and report fee are subject to prior written approval from the WorkSafe Agent.
However sometimes complexity does not emerge until the interview is underway. This requirement does not allow for the emergence of complexity during the interview and should not be included in connection with the proposed fee. By contrast the Transport Accident Commission fee schedule allows for a fee range depending on the level of complexity of the claim. The AMA strongly urges that such a fee range be introduced.
In addition to issues with regard to an ability to work long-term and long-term medical treatment complexity is likely to be indicated by the amount of documentation. It is likely that more than 200 pages of documentation indicates that this is probably a complex claim. It is also likely that an interview using the services of an interpreter will extend the interview time significantly. This is not catered for by this fee schedule.
Feedback from IME psychiatrists is that although the fee increase is helpful it remains rigid and the fee level are still below that of most other states. See NSW SIRA WorkCover fee schedules for 2020 and definitions of a complex claim.
Recommendation 14 (page 227)
Provide guidance and/or training to IMEs regarding:
I think that Recommendation 14 should be reworded as follows:
Recommendation 14 (amended)
Accredit suitable training courses in conjunction with the relevant medical colleges.
Current IMEs should be “grandfathered” but encouraged to participate in such courses.
New IMEs should undertake training as part of their induction to become IMEs
Such training courses should provide for retraining for IMEs about whom concerns have been expressed.
Such training courses should have flexibility to respond to particular concerns including:
Surveillance material such as videos should be seen together with the claimant to provide the claimant with an opportunity to explain the behaviour observed and to confirm that the person in the video is the claimant. It is considered that for an IME to change their opinion on the basis of surveillance material without providing the claimant to comment is unfair.
Other Issues
There are other issues in this document that are of concern. The report notes that in paragraph 615:
Worksafe notes that it did undertake significant external consultation including through the IME Clinical Reference Group, a presentation to the AMA WorkCover/TAC committee, the establishment of a working group with representatives from the College of Surgeons and consultation with various medical faculties and peak bodies in relation to the IME criteria.
The AMA WorkCover/TAC committee were told the issue of a minimum of eight hours “direct clinical care each week” would not be discussed and there was a presentation with little discussion and certainly no agreement.
I also have concerns about this requirement as it seemed to ignore that all colleges have compulsory Continuing Professional Development that is required annually for medical practitioners to retain their registration with AHPRA. It is thought that the process of successful completion of CPD annually is a much more effective tool for determining ongoing clinical competence rather than a minimum of eight hours direct clinical care each week as this, in and of itself, does not imply competence.
Complexity
The ombudsman’s report is a “Follow-Up Investigation into the Management of Complex Workers Compensation Claims”.
Complex workers compensation claims, by definition are – complex!
Complex claims are usually associated with more documentation and an extended interview time. This is particularly the case with regard to complex claims involving alleged mental health issues. See NSW definitions below.
In paragraph 689 WorkSafe wrote:
…in April 2019, WorkSafe increased the fee for psychiatric IMEs by 25% and made other changes to the fee structure such as providing a higher fee if there were more than 20 pages of reading material.
This is the current WorkSafe fee schedule for psychiatrists compare this with the NSW schedule for 2020..
| Item number | Service description | Fee | GST | Total (inc GST) |
| PCT100 | First examination and report – Inclusive of conducting the examination, report writing, reading time and any incidentals (such as postage, photography and faxing services). – Diagnostic tests (such as x-rays) carried out as a necessary part of the examination are not included in the first examination and report item code and will be reimbursed in accordance with WorkSafe policies, the relevant Medicare Benefit Schedule item code and the WorkSafe’s Reimbursement Rates for Medical Practitioners. |
$1,131.02 | $113.10 | $1,244.12 |
| PCT150 | Subsequent examination and report – Applies where a WorkSafe Agent requests a report within 12 months of the first examination and report for the same claim. |
$678.61 | $67.86 | $746.47 |
Psychiatrist – Loadings additional to examination and report fee are subject to prior written approval from the WorkSafe Agent.
| Item number | Service description | Fee | GST | Total (inc GST) |
| PCT200 | Report reading – Flat rate for reading of all reports that accumulatively are greater than 20 pages. – This fee is payable once only per claim per WorkSafe Agent report request. |
$49.72 | $4.97 | $54.69 |
| PCT201 | Report reading – Flat rate for reading of all reports 101 – 200 pages – This fee is payable once only per claim per WorkSafe Agent report request. |
$124.29 | $12.43 | $136.72 |
| PCT202 | Report reading – Flat rate for reading of all reports 201+ pages – This fee is payable once only per claim per WorkSafe Agent report request. |
$207.15 | $20.72 | $227.87 |
The NSW definitions and fee schedule for 2020 illustrate the difference in dealing with complexity.
NSW Workplace Injury Management and Workers Compensation (Medical Examinations and Reports Fees) Order 2020
Definition
MS008 or WIS008 Examination and report – psychiatric $1,426.40
IMS308 or WIS308 Video examination and report – psychiatric $1,426.40
IMS081 or WIS081 Examination conducted with the assistance of an interpreter and report – psychiatric $1,785.60
IMS381 or WIS381 Video examination conducted with the assistance of an interpreter and report – psychiatric $1,785.60
IMS092 or WIS092 Cancellation with 2 working days notice or less, worker or interpreter fails to attend the scheduled appointment/join the video appointment, or the worker or interpreter attends the appointment/joins the video appointment unreasonably late preventing a full examination being conducted. $408.90
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