External case management policy

What will WorkSafe pay

WorkSafe and/or its approved agents will pay the reasonable cost of external case management which is required as a result of a work-related injury or illness under Victorian workers' compensation legislation.

What is external case management?

External case management is a collaborative process which may include assessment, planning and coordination of treatments and services related to a worker’s health needs. This is achieved through communication and utilisation of available resources to promote recovery and maximise independence.

External case management may be considered where the needs of a worker exceed what could reasonably be expected of a WorkSafe or agent case manager. This may be to assist with, but not limited to:

• the coordination of a large care team or sourcing providers
• managing behaviours of concern
• assistance with housing needs
• supporting integration into community services
• promoting maximum independence for workers through planning and support
• time intensive tasks that are beyond the scope of a WorkSafe or Agent case manager
• crisis management
• assistance with the development of self-management skills

WorkSafe recognises that some eligible workers at certain times require assistance beyond the case management role of an agent or the role of treating health care providers to ensure that their health needs are met. Case management services are a time-limited, short term service that complements the agent's role to meet a specific need or goal.

Who can provide external case management services?

External case management services can be provided by case management agencies/providers approved by WorkSafe.

In reviewing registration requests for external case managers, WorkSafe may consider the following:

• Qualifications and experience in the delivery of case management services. A Diploma level or higher is required in a relevant field such as social work, disability, allied health or nursing.
• Evidence of current full/non conditional registration with funding and/or regulatory bodies such as:
  • Australian Health Practitioner Regulation Agency (AHPRA)
  • National Disability Insurance Scheme (NDIS)
  • Department of Families Fairness and Housing (DFFH)
  • or as agreed by WorkSafe to demonstrate that quality and safeguarding standards are in place
• Evidence of current professional indemnity insurance.

Can an external case manager approve services for or on behalf of the injured worker?

External case managers cannot approve any services for or on behalf of a worker.

All services recommended by an external case manager require prior approval by the agent or WorkSafe, who will determine the reasonableness of any requested medical and like or other services.

What can the agent pay for in relation to external case management?

The Agent may pay for external case management where:

• the injured worker is eligible for the Community Integration Program (CIP). Eligibility criteria are detailed in the online claims manual
• the service is authorised by WorkSafe to meet identified short term needs of a worker

Where external case management is requested for workers who are not part of CIP there must be an appropriate justification. This may include, but is not limited to:

• the worker requires assistance to coordinate multiple or complex services/providers beyond what would be reasonably expected of the case manager
• the worker has short or long term complex health needs, however is not eligible for CIP, and requires additional case management supports

A request for external case management for workers that do not meet the above eligibility criteria or are not participating in CIP may be considered by WorkSafe on a case by case basis.

When will WorkSafe not pay for external case management services?

WorkSafe will not pay for external case management services where:

• services are required for an injury, condition or circumstance existing before the work related injury occurred
• services are not required as a direct result of the work related injury
• services do not align with this policy
• the service is based on advocacy. This is not funded by WorkSafe or its agents
• services would be considered as Outreach services (policy link)
• the services are not aligned to health and recovery goals of the worker
• the provider is not approved by WorkSafe to deliver external case management services
• the agent considers that the cost and/or provision of the service is not reasonable, necessary or essential
• the case management objectives identified have previously been addressed
• an injured worker withdraws/refuses to engage in the service
• the external case manager is no longer working to actively achieve outcomes. External case manager responsibilities do not include monitoring. This is the role of the agent

Is prior approval required for payment of external case management?

Prior written approval for external case management services is required.

Request for the provision of external case management services must come from a medical practitioner.

Suspended from providing services to WorkSafe clients

If WorkSafe gives notice to a provider advising them that they are suspended from providing services to WorkSafe clients, WorkSafe will notify their professional body (if applicable) of the suspension and the grounds on which the suspension has been issued.

Note: This policy is a guideline issued by WorkSafe Victoria under Victorian workers compensation legislation in respect of the reasonable costs of services, and services for which approval should be sought from the agent or a self-insurer (as the case may be) before the services are provided.