Proposal 2: Strengthen the assessment of Claims and Injury Management

What are the proposed changes?

We are proposing a package of changes to the Claims and Injury Management (C&IM) process within AEP. These include:

1. Revising and streamlining the C&IM aspects of the AEP audit standards.
2. Removing the current ‘Primary’, ‘Secondary’ and ‘Tertiary’ levels of assessed performance and, instead, requiring AEs to meet all C&IM requirements to remain in AEP.
3. Disestablishing the current external auditor panel and replacing it with a new panel of ACC-approved external assessors. These assessors will have the necessary claim and injury management expertise required to provide sufficient oversight.
4. Strengthening the assessment of claims files undertaken by independent assessors by shifting to an outcome-based focus. Outcomes will make up a number of key measures in Performance Monitoring (see Proposal 3).
   Proposal 3: Performance Monitoring
5. Strengthening the capture of workers’ experience of C&IM, which will feed into the Performance Monitoring model (PM). This will be achieved by:
   1. including more outcome-focused questions for interviews and focus groups, and
   2. introducing tools (such as targeted surveys) to better reflect the journey of injured workers.
6. Requiring an action plan to be developed by AEs when C&IM assessment identifies that an AE is not meeting the required Assessment Standards.
7. Enhancing targeted selection of claim files for assessment, particularly where performance results indicate more scrutiny of C&IM related activities is required.

Why are these changes proposed?

These changes will strengthen the worker engagement and participation in AEP. It will also improve the experience of injured workers and the recovery at work performance of AEs.

Shifting to a performance-based focus will:

• Incentivise AEs to enact and maintain continuous improvement in C&IM; and
• Measure the commitment of AEs towards improving the wellbeing and recovery at work outcomes of their workers.

What options were considered?

The options that were considered in developing this proposal included keeping the status quo and adopting the proposed package of technical improvements. How these options were weighed up is outlined below.

Option 1: status quo

This option would not address the concerns with the current C&IM assessment, and would not generate sufficient data to enable the new PM to work.

Option 2: package of technical improvements to C&IM

This is the favoured option because the technical and operational improvements to C&IM would address concerns by encouraging AEs to focus more on outcomes and workforce engagement. The improvements would also generate the inputs required for the proposed new PM.

How will it work?

What’s new?

The current panel of external auditors will be replaced by a panel of approved assessors with the requisite claims and injury management experience. AEs may continue to select the same independent assessor from this panel for three successive years. The requirement to change assessor after 3 years is to ensure ‘fresh eyes’ after a reasonable interval.

It is also proposed to collect a wider range of information (e.g. targeted surveys) to obtain a more holistic picture of how workers experience the AE’s management of their injury, from claim lodgement to closure. The results will be anonymised and fed into performance monitoring as qualitative input. This will be in addition to reviewing selected claim files against the assessment standards.

Currently, auditors review selected claim files against the assessment standards. Where an assessment identifies that an AE is not meeting requirements, an action plan must be developed by the AE to address the areas of concern, to be reviewed and approved by ACC.

Focus group and claims file interviews

As was mentioned in Proposal One, the new external assessors will, in conjunction with their assessment of C&IM performance, conduct focus group interviews that collect information on both health and safety management and C&IM.

In a separate process, ACC undertakes claims file monitoring and weekly compensation monitoring, to review the intricacies of case management and the accuracy of technical decisions. This also involves claims file assessment interviews with the employee making the claim (and their worker representative if they have one).

It is proposed to strengthen the capture of worker experience by using outcomes-focused questions for claim file assessment interviews and focus group interviews. Findings from claim file assessments, associated interviews, focus group interviews and injured workers’ surveys will be anonymised and fed into performance monitoring as qualitative input.

The frequency of ACC monitoring activities will depend on the overall performance of the AE (e.g. higher performance will result in less frequent claims file monitoring by ACC). Recommendations from claims file monitoring could also trigger further investigation by ACC and/or an out-of-cycle assessment.

What will this mean for Accredited Employers?

AEs that demonstrate high-performance in C&IM can expect a reduction in compliance-based activities. The stronger an AE’s performance, the less claims file monitoring ACC will undertake.

It is proposed to remove the current Primary, Secondary and Tertiary performance levels (see Appendix Two for more detail). Instead, to remain in AEP employers must meet all C&IM requirements described in the updated ACC assessment guidelines and standards.

What will this mean for workers?

The workers’ experiences of claims and injury management practices are important indicators of effectiveness. To get an independent view of the worker experience, claims experience information will be collected by assessors who are independent from both ACC and AEs.

Workers will benefit from increased engagement and participation in the monitoring processes. Over time, this participation should improve the performance of AEs and TPAs.

What will this mean for TPAs?

ACC will continue to assess TPAs’ systems annually with no changes to the timing and process, but the assessment will be against the proposed new C&IM assessment standards. TPAs may benefit from reduced assessment/compliance administration when AEs are considered high performing.

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