External case management policy

The provision of external case management services

These guidelines are in line with the Workplace Injury Rehabilitation and Compensation Act 2013 (WIRC Act) and/or the Accident Compensation Act 1985 (AC Act).

They aim to inform the provision of external case management services to people who have an accepted claim under the Victorian Workers Compensation Scheme.

What will WorkSafe pay

WorkSafe and/or its approved agents will pay the reasonable cost of external case management where required as a result of a work-related injury or illness under 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 following.

• 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 and/or providers approved by WorkSafe.

To ensure external case management providers meet the Social Service Standards, all external case management providers who wish to register with WorkSafe to deliver external case management services must be registered with the Social Services Regulator, under the Social Services Regulation Act 2021.

Proof of registration with the Social Service Regulator must be provided prior to WorkSafe approving and registering an external case management provider.

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

External case managers cannot approve services

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. The agent or WorkSafe will determine the reasonableness of any requested medical and like or other services.

What agents can pay for

The agent may pay for external case management where the following applies.

• The 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 following.
• The worker requires assistance to coordinate multiple or complex services and/or 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.

What WorkSafe will not pay for

WorkSafe will not pay for external case management services where the following applies.

• 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. Advocacy is not funded by WorkSafe or its agents.
• Services would be considered as outreach services.
• 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.
• A worker withdraws and/or 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.

Prior approval is 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.

Suspension 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 under 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.