Australian Government - Comcare

Information for General Practitioners Fact Sheet No 3

The treating doctor’s interactions with other stakeholders

Executive summary

The employee’s treating doctor plays an important role in both providing medical treatment for the injury or disease and working with the case manager and rehabilitation provider to facilitate a return to work. Other stakeholders involved in the management of an employee’s work related injury may be 
  • the case manager employed by the same employer as the injured employee. The case manager facilitates the rehabilitation and return to work process
  • the claims manager employed by Comcare (or a determining authority) to determine liability and manage the employee’s claim for compensation
  • the approved rehabilitation provider, an independent organisation or individual approved by Comcare to provide rehabilitation services. The provider will be contracted by the case manager to facilitate a return to work in consultation with the GP, other health providers, the injured employee and the case manager
  • an independent medical practitioner may be requested by the claims manager to undertake an assessment and provide a report on an injured employee.

The employee’s treating doctor

An injured employee is entitled to seek treatment from the medical practitioner of their choice. The employee’s choice of doctor cannot be overruled by the employer, the case manager or rehabilitation provider, Comcare or the employer’s claims manager.

Employer based medical services

Some large employers may have arrangements in place for medical practitioners or occupational health nurses to provide workplace assessments, emergency treatment and rehabilitation to their employees at their place of employment or close to it.

Case manager

The employer appoints the case manager to facilitate a return to work for their injured employee. The case manager
  • coordinates the notification of injury
  • arranges the assessment of the need for rehabilitation
  • contracts the rehabilitation provider
  • consults with the injured employee and their health practitioners
  • negotiates with managers about suitable duties for the return to work program and
  • organises support for the employee. The case manager arranges for the employee to be referred to a rehabilitation provider where this is necessary and facilitates contact between the rehabilitation provider and the employee’s medical or health practitioners. In consultation with the health practitioners, the case manager will determine the content of the return to work program and work to ensure the commitment of the employee and their manager to it. The case manager negotiates work placements and trials and graduated return to work plans to assist an injured employee to return to work. Where an employee is not able to return to their former duties the case manager may also assist in pursuing redeployment or transfer options in consultation with managers and employee associations. In looking for suitable duties, the case manager will usually be guided by the recommendations made by the treating medical practitioner on the duties and hours of work that would be suitable for the employee. The case manager is normally an employee of the employer — however in certain circumstances this role may have been outsourced to a private organisation. The case manager may request further information from a treating medical practitioner to help resolve or clarify the situation with a particularly difficult or ‘stuck’ case. This could be achieved through either a visit to the doctor’s surgery or a telephone call. A visit to the surgery would normally attract the recommended consultation fee.

Claims manager

The claims manager is either employed by Comcare or by the organisation which manages the employer’s workers’ compensation claims. This may be Comcare, the employer itself, or a contracted claims management agency. The claims manager is responsible for the effective management of an injured employee’s claim. This includes making decisions on the acceptance of liability for periods of incapacity and medical and other benefits. The claims manager may also be required to liaise with the employee, employer, treating doctor and case manager. The claims manager works together with an injured employee and their employer to ensure that the employee receives the protection and entitlements provided by the Safety, Rehabilitation and Compensation Act 1988 (the SRC Act). When a claims manager receives a new claim they must decide if the claim complies with the SRC Act. To be compliant a written claim form is required, usually on a form that has been approved by Comcare or the employer’s insurer, accompanied by a certificate from a legally qualified medical practitioner. If the claim is compliant, the claims manager will then assess if there is sufficient evidence, including medical information, to decide whether liability for the injury or disease should be accepted. If a claims manager cannot make a decision based on the information at hand, they may request further information. The claims manager might ask for witness details, a supervisor’s statement or further medical evidence. The main reason for requesting further medical information is usually to clarify the precise diagnosis of the injury or disease and to establish the connection of the injury or disease with the employment. If the employment nexus is not clearly established, liability will not be accepted. Once all the information is received, the claims manager will be able to decide if the claim should be accepted. Once a decision on liability has been made, the claims manager is required to make a number of other decisions relating to entitlements under the SRC Act. This can include investigating liability for a recommended form of treatment based on the medical evidence that has been provided by the employee. Under the SRC Act, the claims manager must ensure that the treatment is of a therapeutic nature, that it was reasonable for the employee to obtain and that an appropriate cost is charged for that treatment. Fee structures from relevant organisations such as the AMA and WorkCover are used to establish what is appropriate for any given treatment type. In some circumstances a claims manager may request a specialist medical review of a claimant before making a decision on a claim. This might be needed where the medical opinion is inconclusive or where there is a conflict of opinions between doctors involved in the management of the case.

Approved rehabilitation providers

Approved rehabilitation providers are organisations or individuals who are approved by Comcare to provide occupational rehabilitation. They are required to comply with the criteria and standards set by Comcare. Approved rehabilitation providers may be qualified as occupational therapists, rehabilitation counsellors, psychologists, physiotherapists, or social workers. Approved rehabilitation providers can assist the case manager by providing qualified specialist advice about an employee’s needs and assessing the value and type of return to work plan. The approved rehabilitation provider is not employed to treat the condition of an injured employee but rather their services are directly focused on achieving a return to work. The approved rehabilitation provider may need to consult with the treating doctor to assist an employee’s return to suitable duties.

Independent medical review

An independent medical practitioner may be nominated by the claims manager to undertake an assessment and provide a report on an injured employee. The medical practitioner will not previously have been involved in the management of the case and will not be involved in the treatment of the employee. The SRC Act provides a relevant authority, such as Comcare, with the power to require that an employee undergo an examination by a legally qualified medical practitioner nominated by that authority. The claims manager may seek the advice of an independent medical practitioner to obtain an opinion that will assist the claims manager to determine whether or not to accept initial or ongoing liability for a claim. The independent medical practitioner may also be asked for an opinion on proposed treatment, prognosis, fitness for work and loss of use (in relation to permanent impairment). If the employee refuses to attend such an examination, then their rights to claim compensation may be suspended until the examination is undertaken. In normal circumstances, an employee will be requested by the claims manager to take any medical reports, x-rays or other evidence they consider appropriate to this examination. The claims manager will arrange the examination and will provide the examining medical practitioner with the medical evidence available from the employee’s file together with any reports from the employer. The medical practitioner will normally be asked to provide a report of their findings and recommendations together with a response to a schedule of questions forwarded by the claims manager. The independent medical practitioner may therefore have access to information that the treating medical practitioner may not have been given as they will have access to information from both the employee and the employer. In normal circumstances, a copy of the independent medical practitioner’s report will be made available to the employee who may choose to discuss the contents with their own treating doctor. If the specialist considers that their report should not be provided directly to the employee, they may suggest that the information be relayed to the employee through their own doctor.

Fitness for duty examinations

The employer may request an independent assessment, for example from Health Services Australia (formerly the Commonwealth Medical Officer), to determine the employee’s fitness for duty. While this assessment may be undertaken in relation to the employee’s compensable condition, it is not an assessment undertaken for the purposes of determining liability for compensation purposes. Such an examination would assist the employer to establish if the employee’s current duties are suitable or if the person should be redeployed to permanent or temporary alternative duties or if retirement on invalidity grounds should be considered.

Page last updated:November 14, 2007