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Pain Medication Entitlement Annual Renewal

#61 User is offline   waddie 

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Posted 05 September 2007 - 04:24 PM

1Corporation's liability to pay or contribute to cost of treatment



(1)The Corporation is liable to pay or contribute to the cost of the claimant's treatment for personal injury for which the claimant has cover if clause 2 applies,—




(a)to the extent required or permitted under an agreement or contract with any person for the provision of treatment; or




(b)if no such agreement or contract applies, to the extent required or permitted by regulations made under this Act; or




©if paragraphs (a) and (B) do not apply, the cost of the treatment.




(2)In subclause (1)©, cost means the cost—




(a)that is appropriate in the circumstances; and




(b)as agreed by the Corporation and the treatment provider.


Compare: 1998 No 114 Schedule 1 cl 1

2When Corporation is liable to pay cost of treatment



(1)The Corporation is liable to pay the cost of the claimant's treatment if the treatment is for the purpose of restoring the claimant's health to the maximum extent practicable, and the treatment—




(a)is necessary and appropriate, and of the quality required, for that purpose; and




(b)has been, or will be, performed only on the number of occasions necessary for that purpose; and




©has been, or will be, given at a time or place appropriate for that purpose; and




(d)is of a type normally provided by a treatment provider; and




(e)is provided by a treatment provider of a type who is qualified to provide that treatment and who normally provides that treatment; and




(f)has been provided after the Corporation has agreed to the treatment, unless clause 4(2) applies.




(2)In deciding whether subclause (1)(a) to (e) applies to the claimant's treatment, the Corporation must take into account—




(a)the nature and severity of the injury; and




(b)the generally accepted means of treatment for such an injury in New Zealand; and




©the other options available in New Zealand for the treatment of such an injury; and




(d)the cost in New Zealand of the generally accepted means of treatment and of the other options, compared with the benefit that the claimant is likely to receive from the treatment.


3When Corporation is liable to pay or contribute to cost of ancillary services related to treatment



(1)The Corporation is liable to pay or contribute to the cost of any service if the service facilitates the treatment and the service is reasonably required as an ancillary service related to treatment, such as—




(a)accommodation:




(b)escort for transport for treatment:




©pharmaceuticals prescribed by a treatment provider who has statutory authority to prescribe pharmaceuticals:




(d)laboratory tests requested by a registered health professional:




(e)transport (whether emergency or otherwise).




(2)This clause applies subject to any regulations made under this Act.
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#62 User is offline   neddy 

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Posted 05 September 2007 - 04:51 PM

[quote name='waddie' date='Sep 5 2007, 04:24 PM' post='50934']
1Corporation's liability to pay or contribute to cost of treatment




©pharmaceuticals prescribed by a treatment provider who has statutory authority to prescribe pharmaceuticals:

Okay with that Waddie, but please define for me where it says just who the treatment provider is, where it is spelled out with no room to twist or spin.. Is it any provider? somehow I don't think so.

What is being posted are just opinions, not statements that have been tested in the Courts and you can bet that the judiciary would probably find in ACC's favour.
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#63 User is offline   tonyj 

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Posted 05 September 2007 - 05:34 PM

(b)as agreed by the Corporation and the treatment provider.
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#64 User is offline   waddie 

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Posted 05 September 2007 - 05:35 PM

Schedule 1 of the IPRCA 2001 Act

Clause 2(1)(e)is provided by a treatment provider of a type who is qualified to provide that treatment and who normally provides that treatment; and

It is irrelevant whether or not the treatment provider is an ACC contracted provider. For prescribing medication they have to be a registered (with the medical council) medical practitoner.
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#65 User is offline   Alan Thomas 

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Posted 05 September 2007 - 05:47 PM

Medwyn and Neddy a treatment provider will by law have a medical qualification hanging on the wall. If they do not have a treatment provider medical qualification under no circumstances should you bend over because it is probably an ACC case manager asking you to bend over.

I did not think this issue would be so complicated in people's minds. To my mind it is very simple treatment provider decides what treatment you need and ACC have the liability to pay for it once having a look at the treatment providers qualification so the ACC can agree that the treatment provider is the treatment provider.


Waddie seems to have posted the pertinent piece of legislation.

Tonyj appears to have raised the portion of the legislation that the ACC have extrapolated to hell and back to try and wrestle control of treatment from the treatment provider. Perhaps Tony you could enhance what you think the portion of legislation you have posted means in relation to this thread.
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#66 User is offline   waddie 

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Posted 05 September 2007 - 06:22 PM

Tonyj - that bit only relates to the cost of the treatment, nothing to do with the treatment being provided, or the ancillary service. A contracted provider, such as a GP is paid as per an agreed contract, a non-contracted provided according to the regulations. If neither apply then it is the cost of the treatment.

For example, ACC have a contract to pay GPs $x amount of dollars, the GP charges the claimant the rest of his consultation fee. That doesn't give ACC the right to dictate the treatment the GP provides, that is between GP and the patient.

In an appeal I handled Gill v ACC, ACC would not fund a GP prescribing pharmaceuticals prescribed when the claimant phoned the GP to advise she had run out. ACC tried to say that it was not treatment. I submitted that it was because the GP had to exercise his professional skills and that he was not running a take-away food outlet. (I was going to say tinnie house but stop myself). Judge Beattie describe ACC as "arrogant" to imply that prescribing medicine was not treatment. The Lawyer representing ACC then fainted and I had to help her up of the floor. The lessen here is hard to defend the indefensible.

However, that is off the point. The point here, as I understand it, is a medical practitioner prescribe a pain relieving drug (tramadol I think) and ACC decided to not to continue its funding after a certain period. The drug is an ancillary service to the treatment provided by a suitably qualified treatment provider. The pharmacist is providing a service that facilitates the treatment. ACC cannot interfere with that treatment in an arbitrary manner. The circumstances that may be acceptable is if ACC had a specialist opinion that there was a more cost-effective drug and the treatment provider agreed to trial it to see it was effective. The only other circumsatnce would be if the treatment was not for an injury-related need.
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#67 User is offline   neddy 

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Posted 05 September 2007 - 08:01 PM

Thank you Waddie, it in essence answers the question, but also raises questions as well.

What I'm trying to say is there are three fields of play here, the Letter of the Law, The Spirit of the Law, and the Intention of the Law that the writer of the law put on it, then bring it all on into Super Bowl where the field changes yet again when the ACC put their interpretation of the three fields of play and because they may have got away with it, it becomes a precedent in the eyes of DRSL and the courts in general if you get my drift.

I'm not saying Alan or anyone else is not entitled to medication, what I'm saying is that as far as ACC is concerned, they have tested it at Review level and above and have come away with a decision in their favour which to their mind sets a precedent. It will always be a battleground until exactly what someone is deemed to be entitled to is firmly established in non ambiguous words that all parties both understand and adhere to. and that I think is the battle we have to fight, not just issues of entitlement.

I'm not a legal eagle and I hope I have put it out as I see it.
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#68 User is offline   tonyj 

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Posted 05 September 2007 - 09:25 PM

View Postwaddie, on Sep 5 2007, 06:22 PM, said:

Tonyj - that bit only relates to the cost of the treatment, nothing to do with the treatment being provided, or the ancillary service. A contracted provider, such as a GP is paid as per an agreed contract, a non-contracted provided according to the regulations. If neither apply then it is the cost of the treatment.

For example, ACC have a contract to pay GPs $x amount of dollars, the GP charges the claimant the rest of his consultation fee. That doesn't give ACC the right to dictate the treatment the GP provides, that is between GP and the patient.

In an appeal I handled Gill v ACC, ACC would not fund a GP prescribing pharmaceuticals prescribed when the claimant phoned the GP to advise she had run out. ACC tried to say that it was not treatment. I submitted that it was because the GP had to exercise his professional skills and that he was not running a take-away food outlet. (I was going to say tinnie house but stop myself). Judge Beattie describe ACC as "arrogant" to imply that prescribing medicine was not treatment. The Lawyer representing ACC then fainted and I had to help her up of the floor. The lessen here is hard to defend the indefensible.

However, that is off the point. The point here, as I understand it, is a medical practitioner Hi prescribe a pain relieving drug (tramadol I think) and ACC decided to not to continue its funding after a certain period. The drug is an ancillary service to the treatment provided by a suitably qualified treatment provider. The pharmacist is providing a service that facilitates the treatment. ACC cannot interfere with that treatment in an arbitrary manner. The circumstances that may be acceptable is if ACC had a specialist opinion that there was a more cost-effective drug and the treatment provider agreed to trial it to see it was effective. The only other circumsatnce would be if the treatment was not for an injury-related need.


Waddie
I was more inferring he who pays the piper calls the tunes . and its just one of the tools available to discourage service providers from rocking the boat .
There 4 main sources for medications payments , well five if you do as i do and pay myself.

Private medical insurance , not something many of us still have these days .
Pharmac subsidized
Speciali approval DHB / MOH funded
ACC approved

For non Pharmac subsidized meds our two choices are DHB or ACC , both have concerns about expenditure from limited budgets they fork out . They both have policies and systems in place to make it as difficult as possible to get approvals, in part i think wishing to drive you to the other , both create grey areas to frustrate.

Every service industry expert will tell you offer good service, people will come to you , offer bad and off they go to the oppositions..

If the appropriate specialist is firm as to cause and and states without question the medication is significantly more effective and cost beneficial than available subsidized medications either organization should approve it..

But seldom will a DHB or private/ACC funded specialist offer such clarity , so both organizations can disown liability .

In saying that I believe there has been occasions the

(b)as agreed by the Corporation and the treatment provider.

Has been use to infer ACC has a say in agreeing if medications is to be provided .

I find a scripting specialist , who gets his nose out of joint ( with encouragement ) at having his expertise questioned .
In reality it does not matter if its DHB or ACC funded as long as the medication is got..free..

tony
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#69 User is offline   waddie 

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Posted 05 September 2007 - 09:55 PM

Tonyj - the subclause you refer to is the payment to the treatment provider. In Alans case the treatment provider would have been paid for providing the treatment. The medicine is an ancillary service that facilitates the treatment and comes under a different clause.

Not paying for the ancillary service undermines the treatment. In other words, ACC is paying for the treatment provider to do nothing. You may as well write to the anonymous person at ACC and tell them you are in pain and can they please prescribe the appropriate pain relief according to ACC policy.

The thing is different types of pain relief works differently on people. It can require trialling different types before finding the right one that works for you and you type of pain. Achieving pain relief can be the difference between working and not working, exercising and not exercising, etc. For me it was the difference between spending 50% of waking day laying down unable to function and beholding to ACC, and working full-time and being independent of ACC. The last thing you need is ACC screwing with it.
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#70 User is offline   tonyj 

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Posted 05 September 2007 - 11:20 PM

View Postwaddie, on Sep 5 2007, 09:55 PM, said:

Tonyj - the subclause you refer to is the payment to the treatment provider. In Alans case the treatment provider would have been paid for providing the treatment. The medicine is an ancillary service that facilitates the treatment and comes under a different clause.

Not paying for the ancillary service undermines the treatment. In other words, ACC is paying for the treatment provider to do nothing. You may as well write to the anonymous person at ACC and tell them you are in pain and can they please prescribe the appropriate pain relief according to ACC policy.

The thing is different types of pain relief works differently on people. It can require trialling different types before finding the right one that works for you and you type of pain. Achieving pain relief can be the difference between working and not working, exercising and not exercising, etc. For me it was the difference between spending 50% of waking day laying down unable to function and beholding to ACC, and working full-time and being independent of ACC. The last thing you need is ACC screwing with it.


Waddie, not disagreeing with you at all sorry if I gave any other impression .
I was inferring the fact " ACC makes the payment to treatment providers " and in concern to protect these payments some service providers may not be as forceful as they could be.. Its not only claimants who ACC can make life difficult for..
tony

tony
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#71 User is offline   waddie 

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Posted 06 September 2007 - 07:42 AM

Tonyj - A force of habit on my part as an advocate to show how the legislation applies compared to decision-making according to ACC policy or whether Alan is a prick or not.

Your point with treatment providers not being pro-active is an across-the-board problem IMHO. The thing with the treatment providers tend to be submissive because either they seem to have the impression that ACC tells them is what the legislation is when if fact it is "ACC Policy, or that it is to much of a hassle to go against the Beast, or that ACC aren't going to listen to them anyway so it is a waste of time.

That is where claimant representation can give the treatment providers the tool to get the rehabilitation the providers believes the claimant needs. Many treatment providers around here appreciate being able to give their claimant patient a a claimant representative brochure.

So, why is ACC resistant to funding claimant representation when preparing the claimant's rehab plan. Simple, because ACC can't control claimant representatives in the way they can with, say, the endorsed treatment providers the Physios and Warren talked about yesterday.
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#72 User is offline   MadMac 

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Posted 06 September 2007 - 08:13 AM

:wub: High everyone ...

Really interesting ...

ACC have a claim file for ... Pain Syndrome date of accident 7/2/1986

:D Choice as YIPPEE . Well looking at the picture and having aprox 50% or 125 mm of my Right arm crushed over head whilst at work 7/2/1986 , mechanical / structurely recquiring surgery , permanent disability given , permanent muscle/tendon damage, permenaent soft tissue damage having medicially prescribed heaps of pain relief pills , pain block injections ... one would think I would therefore have to some degree Pain Syndrome(s) ... allowing entitlement to Pain Medication Entitlement , appropiate Rehab Plan , appropiate Medicial Treatment / Assistance , Appropiate Case Management of my Claim ?

To get Pain Syndrome firstly must of had an accident causing personal injury(ies) ... yeeeeeep ... injury causing pain ... yeeeeep ... pain treatment to recieve medication.

:o Oooooooops ACC Pain Syndrome ... Declined. Oooooooooooh BUGGER

Interesting ... claim file for ... Sprain / Strain for Injury ... Mmmmmmmmmmmm.

Agree fully No Drsl.

:wub: Have a wonderful day
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#73 User is offline   waddie 

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Posted 06 September 2007 - 08:51 AM

NoDRSL - Your suggestion is far to sensible for ACC or the Government to consider.
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#74 User is offline   Alan Thomas 

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Posted 06 September 2007 - 09:23 AM

No DRSL I used your argument in a review hearing last week concerning ACC's failure to advise me of my entitlement or representation when preparing an IRP. The IRP had been produced without ACC having any regard for information and did not provide me with representation to ensure that my information was represented.

Part of my IRP should have included the medical rehabilitation in place so as it is not confused each year to the extent that ACC think that they can cut it off.
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#75 User is offline   Alan Thomas 

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Posted 06 September 2007 - 09:33 AM

View PostMadMac, on Sep 6 2007, 08:13 AM, said:


:D Choice as YIPPEE . Well looking at the picture and having aprox 50% or 125 mm of my Right arm crushed over head whilst at work 7/2/1986 , mechanical / structurely recquiring surgery , permanent disability given , permanent muscle/tendon damage, permenaent soft tissue damage having medicially prescribed heaps of pain relief pills , pain block injections ... one would think I would therefore have to some degree Pain Syndrome(s) ... allowing entitlement to Pain Medication Entitlement , appropiate Rehab Plan , appropiate Medicial Treatment / Assistance , Appropiate Case Management of my Claim ?

To get Pain Syndrome firstly must of had an accident causing personal injury(ies) ... yeeeeeep ... injury causing pain ... yeeeeep ... pain treatment to recieve medication.




MadMac and raises an interesting point concerning pain syndromes. MadMac is undoubtedly in significant pain and could very well have a pain syndrome overlaying the pain of trying to use the residual structures of his very disorganised arm. It is fair to say that in own so disorganised is not going to function properly and will always be painful to use when asked to carry out tasks beyond the residual capacity. As MadMac there has try to do more than he is capable of doing and does not take pain medication strong enough the likely result is that he will suffer a chronic or regional pain syndrome.

Unfortunately ACC staff frequently gets mixed up on the medical terminology and specialists who become frustrated end up over generalising or using the words on ACC use just so they can get and treatment going.

All chronic pain syndromes are a new injury by way of medical misadventure.

If pain is treated by way of the gold standard of treatment it is very unlikely that a pain syndrome will develop. Pain syndromes can only develop when the pain is not properly controlled. In other words treatment provider fails to treat your pain and the pain pathways are allowed to undergo physiological changes that is a medical misadventure for that failure to provide treatment. This is rather like failing to set a broken leg from which another ailment emerges.

In circumstances where the ACC deny treatment which results in new injuries we are then delving into the area of the crimes act where the ACC has denied the necessities of life which has resulted in actual harm.

Obviously the ACC do not want to acknowledge a chronic pain syndrome in MadMac's case as they would then be open to criminal prosecution. Those who are familiar with this case will realise the enormity of what that would entail.
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#76 User is offline   tonyj 

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Posted 06 September 2007 - 06:28 PM

View Postwaddie, on Sep 6 2007, 07:42 AM, said:

Tonyj - A force of habit on my part as an advocate to show how the legislation applies compared to decision-making according to ACC policy or whether Alan is a prick or not.

Your point with treatment providers not being pro-active is an across-the-board problem IMHO. The thing with the treatment providers tend to be submissive because either they seem to have the impression that ACC tells them is what the legislation is when if fact it is "ACC Policy, or that it is to much of a hassle to go against the Beast, or that ACC aren't going to listen to them anyway so it is a waste of time.

That is where claimant representation can give the treatment providers the tool to get the rehabilitation the providers believes the claimant needs. Many treatment providers around here appreciate being able to give their claimant patient a a claimant representative brochure.

So, why is ACC resistant to funding claimant representation when preparing the claimant's rehab plan. Simple, because ACC can't control claimant representatives in the way they can with, say, the endorsed treatment providers the Physios and Warren talked about yesterday.


It was last century , that I gave up taking ACC on, on behalf of clients utilizing the legislation , DRSL , Reviews , courts or the like.. It was was too stressfully , and frankly the dice was too well loaded in favour of ACC and I was running out of hair to pull out..
I at the same time got to know some wonderful people from ACC and wearing another hat got to see how good they could be when they got it right..
The turning point was when I went to a large conference attended by a CM's TL' and BM from round the country and I got to see close up the attitude and culture as well as the varied levels of skills some CM's had .. it was scary stuff . It was evident a lot of energy energy and focus of ACC was directed at putting in checks and balances to compensate for the less skilled and competent staff ... not to fix problems created but to manage them..The number of people who now have a finger in the pie , having a say , doing reports passing paper , making life or death ( in some cases) calls with absolutely no involvement with the claimant , report after report often by very disinterested specialists who more often than not say what ACC want to hear or put in a throwaway observation so they can appear to have done their moneys worth , that ACC latch onto and a life can get turned up side down..It takes considerable legal and counter medical evidence , often beyond an already vulnerable person to deal with .

I have huge respect for the Advocates like yourself who still have the fortitude to pick up the pieces when things go wrong , and in fact just dealing with the clients themselves deserves a medal..more often than not as a result of the stress and trauma they have suffered .

I now tend to look at the pathway that led to the conflict , the who, what , why and how and get to people BEFORE it goes wrong or address it while its still simple .

You ask..
So, why is ACC resistant to funding claimant representation when preparing the claimant's rehab plan.
end quote.

I really don't know.. I believe the cost benefits to ACC of having informed clients , sound IRP's and the like would reduce the need to have such a huge industry both internally and externally doing all the now required checks , balances and when these fail the spin and ongoing defenses..

I sometimes wonder as well if at some stage if someone did not studiy up on CBT (cognitive behavioral training) and it has become a prime tool in how ACC handle both client and providers as well as ACC front line staff .

Lets hope the new proposed culture we might just see makes it easier for clients to get help before it all goes wrong ..

tony
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#77 User is offline   waddie 

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Posted 06 September 2007 - 07:03 PM

Thanks for the kind comments Tony. I am fast losing hair but my competitive nature is keeps me going. Oh, that and ACC wouldn't employ me. It ain't the money thats for sure.

Basically you have just summed up the big picture in one posting.
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#78 User is offline   doppelganger 

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Posted 06 September 2007 - 08:55 PM

up until the early 90's there were rehabilitation Officers and case officers. the Case Officers worked out when to cut the compensation off and the reason. this was easy for the case officer to do as they just waited for the injured person to ask for rehabilitation stopping rehabilitation.

Management know this and have constructed the KPI's ect to carry out the process. the assessors are just part of it.

interesting in one of the tapes that I have here is an assessor saying that she could not put in job options as she would open her self up to fraud. She could not make different options than had previously been suggested.
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