Role of Healthcare Providers in workers’ compensation

Dr. Luvuyo Dzingwa, RMA GM: Claims & Medical Management

Annually, thousands of workers in South Africa experience the onset of long-lasting or permanent conditions that challenge their ability to work. Irrespective of these conditions having occupational or non-occupational causes, many of these workers are at risk of exiting the labour force, particularly in the absence of timely and effective healthcare provision. This article provides essential information about medical care aspects of the Compensation for Occupational Injuries and Diseases Act, No. 130 of 1993 (COIDA).1 The Act provides compensation for occupational injuries and diseases sustained or contracted by employees, arising out of and in the course of their employment in South Africa.

Workers’ compensation is a medically driven system intended to render injured workers with medical treatment, income protection, permanent loss of function, or organ and fatality benefits. The term ‘medically-driven’ implies that medical information is used to guide fundamental decisions in the system, including acceptance into the system. Healthcare providers (HCPs) play a major role in treating workers who have sustained an injury or developed a disease; simultaneously, they are obliged to submit medical reports. Medical reports are intended to provide the information needed for claims management and treatment coordination and can be uploaded on the Rand Mutual Assurance (RMA) online medical portal, minimising the administrative burden on HCPs.

It is crucial for medical reports to be complete, accurate, conclusive, and well-written, with conclusions that are consistent with the entire report. A comprehensive occupational health history must include information about all the occupations the worker has held, as well as the duration, specific job tasks, time taken to complete different tasks, hazards to which he or she was exposed, and type of protective equipment that was used.

FIRST MEDICAL REPORT

Any work-related accident or incident must be reported to RMA, regardless of the severity. This includes first-aid treated injuries that may need follow-up visits for the purpose of observation, but do not normally need medical care. A doctor or registered professional nurse who rendered first aid treatment must submit the injury as a treat-and-return claim. The HPC attending an injured worker must submit the ‘First Medical Report’ within 24 hours of the initial examination. The HCP must document the nature of the injury, the way it happened, the body parts that were injured, subjective complaints, objective findings, treatment provided, and diagnosis. The worker’s relevant medical history, including pre-existing injuries or disabilities, must be included and, if applicable, the estimated return-to work date for regular work. The report is used to determine the extent of liability based on documented findings and other factors, triggering, and managing the provision of appropriate and timely medical and income protection benefits as prescribed by legislation. Medical reports are critical for determining whether to authorise treatment requests and timely implementation of appropriate case management. This is to ensure that the treatment rendered is reasonable, necessary and justified.

PROGRESS MEDICAL REPORT

When ongoing treatment is provided, a ‘Progress Medical Report’ is required to update and record the patient’s progress regarding the subjective complaints, initial treating HCP’s examination findings, functional status, response to treatment provided to date, diagnoses, treatment plan, and the patient’s work status. Progress reports must be submitted at reasonable intervals – at least monthly, and as soon as possible after the initial examination.

TREATMENT AUTHORISATION REQUEST

Prior authorisation is required from RMA before considered treatment can start, especially non-emergency treatment. RMA will not pay for treatment that is experimental, not evidence-based, unreasonable, or unnecessary, and that would not assist the injured worker in recovery and contribute to the objective of improving the worker’s impairment. The treating HPC is required to submit an online ‘Treatment Authorisation Request’ on the RMA medical portal, which guarantees payment if approved and if the submitted invoice perfectly matches the authorisation. The treating HPC must indicate the treatment requested, which must be substantiated by the injured worker’s diagnosis, including the ICD-10 code, procedure code, and the frequency, quantity, and duration of the requested treatment. The treating HCP must provide a reason for each component of the treatment plan and motivation for any exceptional or protracted course of treatment. Treatment rendered must be consistent with the treatment plan that has been submitted. Treatment plan updates or revisions may be indicated in progress reports, which are regularly required.

FINAL MEDICAL REPORT

When the patient’s condition has reached maximum medical improvement (the point at which the worker’s medical condition has stabilised and further improvement is unlikely), the ‘Final Medical Report’ must be submitted as soon as possible after the examination date by the treating HCP. It must document findings regarding the existence and extent of permanent impairment and limitations, and any need for continuing or future medical care resulting from the injury. The range of motion of the normal opposite or contralateral joint/s must be provided for comparison, where relevant.

It is critical for the treating HPC to understand these complex roles, and how examinations, information and reports can affect the lives of injured workers. The treating HCP must work together with RMA personnel, by completing paperwork on time and supplying information in a timely manner. Delayed benefits to injured workers can cause considerable hardships; many injured workers rely on compensation disability benefits as they have no alternative source of income.