Why is IRO conducting a Medical Disputes Early Solutions Pilot Program (Pilot)?
IRO has a statutory function to assist in finding solutions for disputes between workers and insurers. Matters where the only issue in dispute is a medical treatment claim or expense may be appropriate for intervention to prompt early solutions.
Early solutions
The Pilot program builds on IRO’s existing successful early solutions program. As part of that program IRO currently identifies ILARS-funded matters that may be appropriate for intervention to prompt early solutions between workers and insurers.
The most common type of early solutions matters are cases where an ILARS funding grant had been approved and the insurer had allegedly not responded to a claim or request (No Response To Claim (NRTC) matters) – such as a claim for permanent impairment compensation. In these cases, IRO raises the matter with the insurer to prompt a decision. Where a quick solution is not reached, a decision is subsequently made about any request for additional funding.
The NRTC process is well-established, efficient and effective. It results in quick solutions in hundreds of matters each year. Disputes that otherwise may have needed to go before the Personal Injury Commission (PIC) are solved prior to an Application being made saving time, for all parties, and costs.
How long will the Pilot run?
The Pilot has been extended for 6 months and will run until 31 October 2024 for all insurers.
What are the objectives of the Pilot?
The Pilot aims to find early solutions to disputes between workers and insurers by providing opportunities for:
- Workers and insurers to attempt to resolve a dispute prior to the commencement of proceedings in the PIC
- Insurers to consider all additional evidence available with respect to liability for the claimed medical expense at the earliest opportunity
- Insurers and workers’ representatives to clarify the issues in dispute, where matters cannot be resolved prior to the dispute going before the PIC
Which disputes will be included in the Pilot?
IRO will employ the following expanded eligibility criteria in determining which disputes are eligible for inclusion in the pilot program:
- The matter is eligible for funding through ILARS , based on the requirements set out in the ILARS Funding Guidelines (Guidelines)
- Liability for the medical treatment is disputed
- The dispute may concern aspects of the claim other than medical treatment (i.e. weekly payments, lump sum compensation)
- The insurer has not disputed liability for the injury in the initial s.78 notice and maintained the dispute on all bases in any subsequent s.287A notice
- The claim is not impacted by the operation of section 59A of the Workers Compensation Act 1987
- The proposed treatment is supported by the treating doctor (either nominated treating doctor or specialist/other health professional to whom the worker has been referred by the nominated treating doctor)
- The Approved Lawyer has requested a review under section 287A of the Workplace Injury Management and Workers Compensation Act 1998 (section 287A review)
How many disputes are likely to be captured in the pilot?
It is estimated that fewer than 200 matters a year may fit the eligibility criteria for the Pilot, based on IRO data for previous years.
Therefore, individual insurers may only have a few, if any matters, included in the Pilot.
How will matters be managed in the Pilot?
The Pilot will operate in a similar manner to the existing IRO early solutions NRTC process which is familiar to insurers and lawyers.
IRO will take a proactive role in seeking a further review of the decision to deny liability from the insurer before deciding whether to grant an extension of additional funding to an Approved Lawyer seeking to file an Application in the PIC.
Where a quick solution is not reached, a prompt decision will be made about the request for additional funding.
For insurers
IRO will manage the Pilot in parallel with the current NRTC Complaints process. Matters referred through the Pilot will not be recorded as complaints.
When insurers receive a referral through the Pilot they will be asked to review the denial of liability and reconsider all the available evidence to determine whether they can now accept liability for the claim. If not, they are asked to provide clear reasons for their decision.
Matters progressing through the Pilot will be clearly identified to assist insurers’ triage process.
The high-level process, includes the following steps:
- IRO receives a request for funding that meets Pilot eligibility criteria
- IRO refers disputes to insurers via insurer nominated email and flagged as a Pilot matter
- Insurer response due to IRO within 5 business days
- If a response is not provided, or not adequate, the referral is escalated in accordance with the IRO Complaint Handling Protocol
- Insurers may request an extension of time to respond – any requests for an extension will require the worker’s consent
For lawyers
Lawyers are not required to take any proactive steps to participate in the Pilot.
Lawyers can continue to make applications for funding in line with the Funding Guidelines.
An IRO Principal Lawyer will assess the dispute to determine whether it meets the eligibility criteria for the Pilot.
If a matter is determined to be eligible IRO will contact the insurer and ask it to review the decision to deny liability for the claim.
Through the Pilot, IRO will take a proactive role in seeking a further response from the insurer before deciding whether to grant an extension of additional funding. This is analogous to the existing NRTC process.
Where a quick solution is not reached, a prompt decision will be made about granting funding to an Approved Lawyer seeking to file an Application in the PIC in line with the Guidelines.
Pilot program timeframes
The timeframes that apply to the Pilot are based on our experience in the NRTC process and complaints about medical treatment matters.
As with NRTC matters, the constructive and prompt responses of insurers to Pilot matters will be key in ensuring quick responses, and where possible, solutions.
IRO will also monitor timeframes once the Pilot program is underway.
Will dispute resolution be delayed or injured workers disadvantaged by the Pilot?
The Pilot will not change the ability for Approved Lawyers to receive ILARS funding and does not change any of the current funding criteria in the ILARS Guidelines.
When an ILARS Principal Lawyer receives a request for funding and determines that the matter is eligible to participate, the matter will be referred to the Pilot before the request for funding is assessed.
However, if the treatment request is urgent, or any delay in lodging an Application with the PIC may cause significant disadvantage to the worker, the Approved Lawyer can contact IRO to seek an earlier decision about funding. In these matters IRO may still seek a response from the insurer, even where an extension of funding is also granted, and consistent with the intention of the Pilot.
Any extensions of time required by the insurer will only be granted with the injured worker’s consent.
Are there any costs involved with running the Pilot?
The Pilot will be run in line with existing resourcing and IRO has not experienced any costs increases resulting from it.
For participants IRO does not envisage an increase in the need for legal funding given its close relationship with the current NRTC process. In matters where an early solution is achieved, the legal costs will be less for both the parties than had the matter proceeded to the PIC.
How does the Pilot relate to the PIC’s dispute resolution function?
The Pilot does not duplicate the processes of the PIC. It does not attempt to conciliate between parties or impose a resolution in any dispute.
When insurers receive a referral through the Pilot they will be asked to review the denial of liability and reconsider all the available evidence to determine whether they can now accept liability for the claim. If not, they are asked to provide clear reasons for their decision.
What are the success criteria for the Pilot?
IRO will assess the success of the Pilot based on whether it meets the objectives driving early solutions. Success criteria will include:
- A comparison of the number/proportion of matters which resolve prior to the commencement of proceedings before and after the implementation of the Pilot.
- Review the stage at which matters resolve once in the PIC and the time taken for grants to be finalised.
- Assessing the time and cost value of any savings achieved through the Pilot.
What will happen after Pilot concludes?
Once the Pilot concludes IRO will review the quantitative and qualitative data collected. IRO will determine whether the Pilot process continues, requires amendment, and the potential for expansion or adoption as part of our existing early solutions work.