Module 1: The Medication Problem in the Scheme

Why this reading matters

The video introduced medication as the invisible treatment: present on almost every claim, running every day, and the treatment least likely to be reviewed. This reading goes further. It explains the mechanics of how a reasonable start turns into a long, expensive claim, works through a de-identified file from injury to week 30, and sets out the mistakes case managers most often make when medication is in the picture. By the end you should be able to explain, in your own words and to your own team leader, why medication deserves a place on your review checklist.

How medication changes the shape of a claim

Most claims are managed around services you approve: physiotherapy sessions, psychology, surgery, a graded return to work plan. Each of these passes through a decision point on the claim, so each gets looked at.

Medication is different. It is started by a treating doctor, filled at a pharmacy, and often paid for through pharmacy invoices that arrive in batches. There is no natural decision point where someone asks "is this still working?" That is the structural reason medication goes unreviewed. It is not that case managers are careless. It is that the process was never designed to look.

There are three ways unreviewed medication extends a claim.

1. It reduces capacity directly. Sedation, slowed thinking, dizziness and poor concentration all reduce what a person can safely do at work. A certificate that restricts driving, operating machinery or working at heights may be reflecting the medication as much as the injury.

2. It creates new problems that look like new conditions. Weight gain, low mood, poor sleep, cognitive complaints and worsening pain are all recognised effects of commonly used medicines. When they appear, they tend to be investigated as conditions in their own right.

3. It makes recovery harder to finish. The longer certain medicines are taken, the harder they are to stop. A regimen that could have been simplified at week 8 with little difficulty may need a slow, supervised plan by week 40. Every month of delay adds to that.

The secondary condition pathway

The video introduced the chain: medication effect, new diagnosis, new investigations, new liability. It is worth slowing down on each link, because this is where cost and duration accumulate.

In many schemes, a condition that arises from reasonable treatment of the compensable injury can itself become compensable. Check your own scheme's rules, but the principle is common. That means the moment to ask "could this be the medication?" is before the investigation pathway starts, not after the condition has been accepted.

In IMM's experience, each accepted secondary condition investigation that can be avoided is worth around $50,000, before counting the delay to return to work. You will not avoid every one, and many secondary conditions are genuine. The point is that asking the question early is cheap, and not asking it can be very expensive.

The two questions, worked through

Every time something new appears on a file, ask two questions:

1. Is this a medication problem or a condition problem?
2. Are we liable for it or not?

These two questions are deliberately separate, because they belong to different people.

The first question is clinical. You do not answer it. You ask it, and you make sure a clinician who can answer it is asked. If nobody asks, the default assumption is that every new symptom is a condition, and the claim follows the condition path.

The second question is yours. It is a claim decision, guided by your scheme's legislation, policies and advice. You make it better when you know the answer to the first question, or at least know that the first question has been asked.

Here is how the two questions change the conversation in four common situations.

Notice that in none of these examples does the case manager decline anything or decide anything clinical. They add a question at the right time, to the right person.

The intervention window

The brief timeline is worth committing to memory.

• Weeks 4 to 12: the best window to act. Early medicines have had time to work or not work. Patterns are forming but habits have not set in. Prescribers and claimants are more open to changes.
• Weeks 12 to 26: regimens become complex. Doses climb, and new medicines are added to manage effects of earlier ones.
• Review triggers: week 12, week 26 and before week 52. At each, ask whether anyone has looked at the whole medication picture recently.

Why is early better? Think about it from the claimant's side. At week 6, a person who has been taking a medicine for a month may be uncertain whether it helps and may welcome a review. At week 40, the same person may feel that the medicine is the only thing holding them together, may be anxious about any change, and may experience real withdrawal effects if anything is altered quickly. The clinical work is harder, slower and more distressing for everyone.

From the prescriber's side, a question at week 6 reads as routine. A question at week 40 can read as criticism of months of prescribing, which makes the conversation harder.

A realistic file example

The following file is de-identified and simplified. Names and details are invented.

Claimant: "Ms R", 46, aged care worker. Lifting injury, lower back. Accepted workers' compensation claim.

Week 1. GP diagnoses lumbar strain. Prescribes an anti-inflammatory and a short supply of oxycodone 5 mg tablets. Certificate: modified duties, no lifting over 5 kg.

Week 3. Pain persisting. Oxycodone continued. Physiotherapy approved.

Week 6. GP notes "possible nerve involvement", adds pregabalin 75 mg twice daily. Certificate changes to unfit for work for two weeks.

Week 9. Pregabalin increased to 150 mg twice daily. Claimant reports poor sleep. GP adds temazepam at night.

Week 12. Physio reports "slow progress, claimant tired and found it hard to follow the home program". Certificate: "fatigue, poor concentration".

Week 15. Claimant reports weight gain of 6 kg and low mood. GP prescribes sertraline and requests a psychology referral for "adjustment disorder with depressed mood".

Week 18. Psychology approved. Claimant tells the case manager she "feels like a zombie" in the mornings.

Week 22. GP requests a referral to a pain specialist. Pain now described as "worse and spreading to the hips".

Week 26. Specialist increases opioid to a controlled-release formulation. Psychological injury claimed as a secondary condition. Return to work date pushed out indefinitely.

Week 30. File is reviewed for the first time by a clinical pharmacist after a team leader audit.

What happened here

Look at the file through the lens of this module. Every prescribing decision had a plausible reason. Nobody acted unreasonably on the information they had. But nobody stepped back.

• At week 9, the claimant was on an opioid, a gabapentinoid and a benzodiazepine. That was the moment the regimen moved from simple to complex, and it fell squarely in the intervention window.
• At week 12, the certificate recorded fatigue and poor concentration. This was the first review trigger, and a natural point to ask the first question.
• At week 15, weight gain and low mood appeared after pregabalin had been increased and a benzodiazepine added. Both are recognised effects of medicines on the list. The response was another medicine and a referral.
• At week 22, pain was spreading despite ongoing opioid use. That pattern is one of the reasons Module 3 will ask you to consider whether pain is the injury or partly the medication.
• At week 26, a secondary condition was claimed.

What asking the two questions might have changed

If the case manager had asked "medication or condition?" at week 12, the most likely next step would have been a request to the GP for the medication plan, or a clinical pharmacist review. That does not guarantee a different outcome. It may have shown the regimen was appropriate. But it would have put the question in front of a clinician before the psychology referral, the pain specialist referral and the secondary condition claim. And it would have left a clear record that the insurer identified a risk and acted on it.

The NSW "reasonable and necessary" test

In New South Wales, the NSW workers' compensation reforms (Workers Compensation Legislation Amendment Act 2025) changed the test for treatment expenses from "reasonably necessary" to "reasonable and necessary", with effect from 01/10/2026. NSW CTP already uses "reasonable and necessary". This raises the evidence needed for medication decisions. Long-term regimens, polypharmacy, opioids and medicinal cannabis now need stronger clinical justification, and other schemes are signalling the same direction.

What does this mean in practice for a case manager?

• It cuts both ways. You need a clearer basis to approve or continue long-term medication funding, and a clearer basis to dispute it.
• A defensible file needs a clinical picture. "The GP prescribed it" is a weaker basis than it used to be, particularly for regimens that have run for months.
• Documentation matters. A file note showing that the medication picture was reviewed, by whom and with what outcome, is part of a defensible decision trail.

If you work outside NSW, follow your own scheme's legislation and guidance. The direction of travel described in the brief is the reason to build good habits now.

Common mistakes

Assuming the GP has the whole picture. The GP may not know what a specialist prescribed, what was bought over the counter, or which pharmacy was used. The GP is usually the right person to ask, but should not be assumed to hold every piece.

Treating medication as outside your role. Your role is not to judge prescribing. It is to notice, ask and escalate. Leaving medication out of your review entirely is a gap, not a neutral position.

Waiting for a problem to become obvious. By the time medication harm is obvious, the regimen is usually complex and the claim has already changed shape. The intervention window is about acting before it is obvious.

Approving secondary condition investigations without asking the first question. The investigation may still be appropriate. But the question costs little and can change the pathway.

Framing the question as a criticism. "Why is she on all these medicines?" puts a prescriber on the defensive. "Could you advise the plan and expected duration?" invites an answer. Module 6 covers this in detail.

Using the claimant's own words as a diagnosis. A claimant who says "I think the tablets are making me depressed" is giving you useful information, not a conclusion. Record it factually and escalate it. Do not agree or disagree with it.

Building the habit

You do not need new systems to start. Three small habits make a difference.

1. Add medication to your week 12, week 26 and pre-week 52 review checklist. Ask one question: has anyone looked at the whole medication picture recently?
2. When something new appears, write the two questions in your file note. Even "Medication or condition: not yet asked. Action: request medication plan from GP" changes the record.
3. Notice the words. Fatigue, concentration, weight, mood, sleep, unsteady, foggy. These words on certificates and reports are prompts, not conclusions.

What changes when someone looks

IMM's 2025 outcomes show what is possible when medication is reviewed properly. After pharmacist review, 43% of people ceased opioids, 36% ceased benzodiazepines and 33% ceased gabapentinoids. And 81% of IMM's recommendations are implemented by the treating prescriber.

The 81% figure is the one to remember. It tells you that prescribers generally welcome a clear, evidence-based view of the whole picture. They rarely have time to build one themselves. Your role creates the opportunity for that view to reach them.

Key points

• Medication is on almost every claim and is the treatment least often reviewed, because no natural decision point exists for it.
• Unreviewed medication extends claims by reducing capacity, creating apparent new conditions and becoming harder to stop over time.
• A medication effect accepted as a condition brings its own investigations, treatment and liability.
• Ask two questions whenever something new appears: medication or condition, and liable or not. The first is clinical and you ask it; the second is yours to decide.
• Weeks 4 to 12 are the best window to act. Regimens become complex between weeks 12 and 26. Review at week 12, week 26 and before week 52.
• In NSW, the reforms that took effect on 01/10/2026 made "reasonable and necessary" the test for treatment expenses, raising the evidence needed for medication decisions in both directions.
• Your role is notice, ask, escalate. You never diagnose and never recommend medication changes.