Download Human resources for managing claims

External Guideline #14
Human resources for
managing claims
Version 6
1 April 2015
WorkSafe Victoria
Human resources for managing claims
Contents
1.
Preface ................................................................................................................................ 3
2.
Overview ............................................................................................................................. 3
3.
Functions relevant for managing claims .......................................................................... 4
3.1
Primary claims management function ...........................................................................................4
3.2
Technical and legal function .............................................................................................................5
3.3
Injury management function .............................................................................................................6
3.4
Claims administration support function ........................................................................................7
4.
Maintaining up to date claims management knowledge ................................................. 7
5.
Sufficient employee resources for managing claims ...................................................... 8
6.
Relevant competencies ..................................................................................................... 8
7.
Additional notes ................................................................................................................. 9
8.
Further information ............................................................................................................ 9
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Human resources for managing claims
1. Preface
This guide has been developed to assist applicants for approval or for renewal of approval as
a self-insurer in understanding what WorkSafe Victoria1 (WorkSafe) considers relevant when
assessing an employer’s current or proposed human resources for managing claims2.
The guide provides a framework for assessing the human resources that employers have in
place for managing claims. However, WorkSafe does not consider this to be the only way
that employers may demonstrate sufficient human resources for managing claims, rather it
represents one avenue. Self-insurers have discretion to determine appropriate human
resource arrangements for their organisation. Where an employer’s arrangements differ from
the guide, these will be considered by WorkSafe on a case-by-case basis and in the context
of claims management performance outcomes.
This guide is intended for use in the following manner:

by prospective, new or existing self-insurers to inform their human resource planning for
managing claims

as a reference in the assessment of applicants for approval, or for renewal of approval,
as a self-insurer; and

as a reference point to facilitate discussion between WorkSafe and a self-insurer should
a concern with claims management performance arise.
In addition to assessing the human resource arrangements in place, where available,
performance-based indicators are also considered in assessing the adequacy of an
applicant’s human resources for managing claims.
2. Overview
Broadly, WorkSafe will assess whether an applicant for self-insurance is likely to have
sufficient human resources with the range of knowledge and skills to ensure appropriate
management of all claims administered or likely to be administered, and/or that they can
access external specialist expertise as and when required. Where external expertise is
engaged, the self-insurer maintains ultimate responsibility for the management of the claims.
1
2
‘WorkSafe Victoria’ is a trading name of the Victorian WorkCover Authority.
Subsection 379(4)(b) of the Workplace Injury Rehabilitation and Compensation Act 2013 (WIRC Act) states that ‘in determining
whether an employer is fit and proper to be a self-insurer, WorkSafe must have regard to – (…) the resources, including employees,
that the employer has for the purpose of administering claims for compensation’. This includes claims management and return to
work functions.
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3. Functions relevant for managing claims
To effectively manage claims, WorkSafe considers that the following four functions are
important:

primary claims management function

technical and legal function

injury management function; and

claims administration support function.
Depending on the employer, it may be that one individual performs all or some of these
functions; that the functions are performed by separate individuals; and/or that the employer
sources the necessary expertise externally.
In submitting an application for approval, or for renewal of approval, as a self-insurer,
supporting material submitted3 should show how these functions are addressed by the
organisation.
An explanation of each function is provided below.
3.1 Primary claims management function
This involves responsibility and accountability for each claim in the portfolio and includes
carrying out end-to-end management of all types of claims in accordance with the Workplace
Injury Rehabilitation and Compensation Act 2013 (WIRC Act) and where applicable the
Accident Compensation Act 1985 (ACA). This function would draw on additional expertise as
and when required, but maintains ultimate responsibility for the effective management of the
claims.
Examples of the types of responsibilities this function would include are:
3

planning the approach for managing each claim and coordinating all activities

determining initial liability and ongoing entitlement to compensation for each claim

arranging independent medical examinations

paying appropriate compensation to workers

facilitating early injury recovery and successful return to work
Please also refer to:
 the External Guideline #2 - Assessment of initial application for approval as a self-insurer or External Guideline #3 – Assessment
of application for renewal of approval as a self-insurer which outline the information and indicators that WorkSafe will have regard
to when an employer applies for approval or renewal of approval as a self-insurer; and
 the External Form #2 - Application for approval as a self-insurer and External Form #3 – Application for renewal of approval as a
self-insurer which outline the supporting information that applicants need to submit.
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
ongoing communication with the worker and other relevant parties

establishing and reviewing case estimates for costs of claims

undertaking regular reviews of claims

accessing relevant injury management specialists / expertise, such as medical and
return to work expertise

managing providers (for example, private investigators, independent medical
examiners)

accessing relevant technical and legal expertise as and when required

liaising with relevant experts in the management of impairment benefit claims; and

managing dispute resolution activities, including attendance at conciliation when
required.
WorkSafe will look for appropriately skilled employees having responsibility for performing this
function. For the primary claims management function this may be demonstrated via proven
experience in a personal injury claims management role that demonstrates the ability to
undertake end-to-end claims management.
Whilst not mandatory, qualifications that may assist in demonstrating relevant skills and
knowledge for this function include the Certificate IV in Financial Services (relevant units of
competency) or equivalent.
3.2 Technical and legal function
This relates specifically to ensuring that the technical and legal analysis necessary in claims
management is available.
Such analysis would be required in relation to, for example:

compensation payments and the requirements of the WIRC Act and the ACA where
applicable

impairment benefits

determination of liability and management of death claims

dispute resolution

legal case management

identifying claims which would be considered scheme sensitive and related liaison with
WorkSafe

identifying claims that may lead to the commencement of legal proceedings; and
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
identifying when to refer a matter for further legal advice.
WorkSafe will look for appropriately skilled employees having responsibility for performing this
function, and/or that this expertise is available as and when required. For the technical and
legal function this may be demonstrated via proven experience in statutory personal injury field
that demonstrates strong technical and legal knowledge, including knowledge of the WIRC
Act.
Whilst not mandatory, qualifications that may assist in demonstrating relevant skills and
knowledge for this function include:

Bachelor of Laws Degree (LLB); or

Diploma of Financial Services (relevant units of competency) or equivalent.
Where relevant, WorkSafe would consider information about the employer’s arrangements for
accessing external legal expertise.
3.3 Injury management function
The focus of this function is the injury management and occupational rehabilitation activities
required during the life of a claim.
Examples of the type of responsibilities this function would include are:

provision of advice regarding treatment, rehabilitation and return-to-work

deciding whether a medical specialist is needed for diagnosis, prognosis or other
specialist advice

managing health and rehabilitation providers

liaising with external parties who influence the worker’s rehabilitation, fitness to return to
work and future work duties; and

determining what are reasonable medical and like costs as they relate to the workers’
claimed injury or injuries.
WorkSafe will look for appropriately skilled employees having responsibility for performing this
function, and/or that this expertise is available as and when required. For the injury
management function this may be demonstrated via proven experience in workplace based
rehabilitation. Alternatively this may be demonstrated via qualifications in a medical, health or
related area4.
4
For example, diploma, degree or graduate diploma in medicine, health science, behavioural science, social work or rehabilitation
counselling, or eligibility for registration as a Division 1 Nurse in accordance with requirements as established by the Nurses Board of
Victoria.
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Whilst not mandatory, other qualifications that may assist in demonstrating relevant skills and
knowledge for this function include the Diploma of Financial Services (relevant units of
competency) or equivalent.
In addition, WorkSafe would review evidence of the arrangements in place for:

occupational rehabilitation providers

return to work coordinators; and

access to other relevant medical expertise as and when required.
3.4 Claims administration support function
The focus of this function is administrative and data entry activities, such as payment and
recording of invoices. This function may also assist in less complex claims management
activities.
WorkSafe will look for appropriately skilled employees having responsibility for performing this
function. For the claims administration support function this may be demonstrated via
experience gained in the role through workplace-based training and development.
Whilst not mandatory, other qualifications that may assist in demonstrating relevant skills and
knowledge for this function include Certificate III in Financial Services (relevant units of
competency) or equivalent.
4. Maintaining up to date claims management knowledge
To effectively perform the claims management functions identified, self-insurers will need to
maintain up-to-date knowledge in relevant areas.
In the supporting material provided by the applicant, for example, WorkSafe will look for
training programs delivered or likely to be delivered and other relevant activities. Examples of
training and development that would be considered in WorkSafe’s assessment of employees
involved in managing claims include:

induction and training programs conducted or planned by self-insurers for relevant
personnel

participation in legislative updates and briefings

participation in Impairment Benefits training

participation in Approved Return to Work Coordinator training; and

other relevant development activities conducted or planned.
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5. Sufficient employee resources for managing claims
The number of claims being managed per claims officer or full time equivalent is taken into
consideration when WorkSafe is assessing whether there are sufficient human resources for
administering claims. This is undertaken on an individual basis as it needs to be considered
in connection with many other relevant factors including the:

types of claims that the self-insurer manages or is likely to manage

nature and complexity of claims that the self-insurer manages or is likely to manage; and

individual self-insurer’s claims administration arrangements (e.g., allocation of
responsibilities; additional responsibilities held by employees administering claims).
As a guide (not mandatory), for the more complex claims5, the role that has primary
responsibility for managing claims (Case Manager) may manage a maximum of 80 active
claims6 at any one time. It is important to note that in performing this role, the Case Manager
is supported and can access resources and expertise as necessary.
6. Relevant competencies
WorkSafe considers that certain competencies contribute to effective claims management.
Whilst not directly applicable to self-insurers, the following competencies are used by
WorkSafe’s Agents in the recruitment of, for example, Case Managers:

communication and influencing techniques

customer service and stakeholder management

analysis, judgement and decision making

professional and technical competency

understanding and managing WorkSafe Scheme Objective

planning and organising / time management; and

cultural fit.
A description of these competencies (as defined for WorkSafe‘s Agents) may be obtained by
applicants for information.
5
6
More complex claims include for example, over excess claims with no full return to work; mental injury claims; death claims; hearing
loss claims; claims where an impairment benefit application is received; claims for heart disease or cancer.
Active claims are where:

A weekly benefit payment has been made in the prior three months for time lost that occurred within 90 days of the payment
date;

A medical benefit payment has been made in the prior three months for a medical service provided within 90 days of the
payment date; or

Any payment has been made in the prior three months for any service (including common law, rehabilitation, investigation
costs, etc) provided within 90 days of the payment date.
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7. Additional notes
Where a self-insurer has (or proposes to have) an appointed agent for the management of
claims under section 392 of the WIRC Act, WorkSafe will also consider the agent’s resources
for administering the self-insurer’s claims. This guide will also be relevant in these
circumstances. Where such arrangements are in place, additional requirements exist
regarding, for example, a statement of respective responsibilities of the proposed agent and
the self-insurer. Such requirements are addressed separately in External Guideline & Form
#4 - Application for a person to act as an agent of a self-insurer.
In addition to the human resources required for managing claims, a self-insurer will need
sufficient employee resources to perform other functions required of self-insurers, for
example:
Electronic Data
Transfer
Excess of Loss
Certification
TAC Arrangements
Self-audits & Other
Audits
Licence Renewal
Workplace Data
Contribution
WorkSafe Surveys
Team Management
Bank Guarantee
Declaration of Wages
Financial Management
While necessary, such functions are not included in this guide as they are not direct claims
management functions considered under subsection 379(4)(b) of the WIRC Act.
8. Further information
Requests for further information relating to human resources for managing claims should be
directed to:
Manager - Self-insurance Operations
Insurance Division
WorkSafe Victoria
222 Exhibition Street
Melbourne VIC 3000
Phone: 03 9641 1444
Freecall: 1800 136 089
Fax: 03 9641 1708
Email: [email protected]
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