Inconsistencies in a Job Capacity Assessment (JCA) report 008-06070110

Staff may access the entire contents of the completed Job Capacity Assessment (JCA) report and Disability Medical Assessment (DMA) electronically and may view and print the report as required.

After it is submitted, the JCA report will require manual checking and actioning. Inconsistencies may include, but are not limited to:

• Inconsistent work capacities (and rationale)
• Incorrect application of impairment ratings (including incorrect table)
• Incorrect or absent assessment of medical information (except where this has been supplied after the JCA appointment)
• Incorrect or absent assessment of Program of Support requirements
• Incomplete specialist assessment, including provision of specialist report
• The customer's functional impairment is not congruent with medical information (the functional impairment should reasonably align with the medical condition)

Note: if the JCA report has inconsistencies or errors and cannot be accepted, refer to Checking and actioning a Job Capacity Assessment (JCA) report. Assessment Services will review the query and relevant JCA report.

From 15 May 2021, a new internal review and appeal process means a customer may request an explanation or a review of a decision.

SME quality check requested before 15 May 2021

Where a customer has requested a Subject Matter Expert (SME) quality check of a decision after a DSP claim has been rejected on the basis of a MAT or JCA, and new medical evidence has been provided or the SME identifies an error in the original decision recommendation, the case must be returned to the Medical Assessment Team (MAT).

MAT determines if an appeal JCA is required. The MAT Assessor generally organises a direct JCA referral. However, MAT Assessors not trained in the JCA referral process take the DSP ODM DOC off hold for allocation to a SME to complete the JCA referral.

For more information, see Reviews and appeals for Disability Support Pension (DSP) rejection or cancellation decisions.

If a DSP appeal JCA report is submitted the SME must manually check and action the JCA report.

If the submitted DSP Appeal JCA report has inconsistencies or errors and cannot be accepted, see Checking and Actioning a Job Capacity Assessment (JCA) report.

Explanation requested on or after 15 May 2021

Where a customer has requested a SME explanation of decision after a DSP claim has been rejected on the basis of a MAT or JCA, and new medical evidence has been provided or the SME identifies an error in the original decision recommendation, the case must be returned to Medical Assessment Team (MAT).

MAT determines if an appeal JCA is required.

If an appeal JCA is required MAT must take the SME Explanation DOC off hold so the work item presents back to the SME for actioning.

The SME requests the DSP Appeal JCA referral and refers the case to an ARO by running the Internal Review/Explanation script. See Reviews and appeals for Disability Support Pension (DSP) rejection or cancellation decisions.

The SME should also determine if an Administrative Review Tribunal (ART) appeal is in progress. If one is, the SME needs to contact the LB advocate to advise of any new information provided.

Once the MAT assessment has been completed, the SME is to review the MAT outcome. If a quality issue is identified, the SME is to refer back to the MAT via DSP MAT Query Fast Note and select the relevant option.

For more information about referring to MAT and actions following their recommendation, see Reviews and appeals for Disability Support Pension (DSP) rejection or cancellation decisions.

A customer may apply for a formal review of a decision which is provided by an Authorised Review Officer (ARO).

The ARO considers whether or not they have sufficient medical evidence and information to make a decision on the customer's appeal, whether this is to affirm, set aside or vary the original decision.

If the ARO does not have sufficient information, further information may be sought from a variety of sources including the customer, the customer's treating doctor or specialist, the HPAU and the Assessor (MAT or JCA).

If an ARO seeks assistance from the HPAU, HPAU ensures a single agency view is provided. This may include consultation with the relevant Assessor.

Clarifying rationale or considering new medical information or historical information that may not have previously been assessed can reduce the need for further JCA’s. It also indirectly provides valuable feedback to Assessors about changes in the customer's condition or treatment as well as those areas of their report used by staff for making decisions on payment eligibility.

The ARO may determine there are inconsistencies or errors within the report that was accepted and used as part of the original decision or for an appeal JCA. These may include, but are not limited to:

• inconsistent work capacities (and rationale)
• incorrect application of impairment ratings (including incorrect table)
• incorrect or absent assessment of medical information (except where this has been supplied after the JCA appointment)
• incorrect or absent assessment of program of support requirements
• incomplete specialist assessment, including provision of specialist report
• the customer's functional impairment is not congruent with medical information (the functional impairment should reasonably align with the medical condition)

For more information on how to check if a JCA report has inconsistencies or errors, see Checking and actioning a Job Capacity Assessment (JCA) report.

Whether it is for an original JCA or for an appeal JCA, ARO’s are required to address reports with inconsistencies or errors. The ARO:

• May seek advice or clarification from HPAU
• Will email the Assessment Services Quality Team (using the approved JCA email template) if the content of the JCA report is incorrect
• Can liaise with Assessment Services to discuss their intention to set aside the decision to reject the DSP claim

Assessment Services will review the query and relevant JCA report, and if appropriate, refer the matter to the HPAU for opinion and advice.

Note: except where manifest eligibility is established, an ARO cannot set aside a DSP rejection and substitute a grant decision unless the customer has undergone a Disability Medical Assessment (DMA) with a Government-contracted Doctor (GCD).

For more information see Reviews by an Authorised Review Officer (ARO).

CIS SMEs may seek assistance when making decisions about complex matters regarding impairment and work capacity for foreign pension, portability and agreement claim matters.

When a JCA report is checked, CIS Officers may identify inconsistencies within the report. These include but are not limited to:

• inconsistent work capacities (and rationale)
• incorrect application of impairment ratings (including incorrect table)
• incorrect or absent assessment of medical information (except where this has been supplied after the JCA appointment)
• incorrect or absent assessment of program of support requirements
• incomplete specialist assessment, including provision of specialist report
• the customer's functional impairment is not congruent with medical information (the functional impairment should reasonably align with the medical condition)

The matter is forwarded to the Team Leader at CIS who reviews the matter and forwards it for review to the Assessment Services Quality Team mailbox if appropriate.

Assessment Services:

• review the matter
• escalate recommendations to the Team Manager and to the Business Manager
• communicate to the Team Leader is CIS about changes that are required, the action taken and any progress made
• if appropriate, refer the matter to the HPAU for opinion and advice

LB lawyers may seek assistance from Assessment Services if a customer has had a decision set aside by the Administrative Review Tribunal (ART) ART first review on the basis of significant new medical evidence, or a customer submits new medical evidence in the course of an ART appeal. These cases will be referred to the JCA.BSU mailbox for action.

Litigation Branch may request a file review JCA to consider such evidence. A 'DSP Appeal' JCA will be booked as a file review. In all cases the Assessor must liaise with HPAU to ensure that the conclusions expressed in their report regarding functional impairment and work capacity accurately represent the view of Services Australia. Assessment Services is required to respond within agreed timeframes to facilitate the tribunal timeframes.

Litigation Branch may be made aware of detrimental findings or at review identify inconsistencies within the report. These include but are not limited to:

• inconsistent work capacities (and rationale)
• incorrect application of impairment ratings (including incorrect table)
• incorrect or absent assessment of medical information (except where this has been supplied after the JCA appointment)
• incorrect or absent assessment of program of support requirements
• incomplete specialist assessment, including provision of specialist report
• the customer's functional impairment is not congruent with medical information (the functional impairment should reasonably align with the medical condition)

The matter is forwarded to the manager at PLR who reviews the matter and forwards for review to the Assessment Services Quality Team mailbox.

Assessment Services:

• review the matter
• escalate recommendations to the Team Manager and to the Business Manager
• communicate to the manager at LB about changes that are required, the action taken and any progress made
• if appropriate, refer the matter to the HPAU for opinion and advice

There may be differing opinion between the Assessor and the HPAU's consulting Health or Allied Health Professionals. This is a natural part of professionals working together and the collaboration process. The Assessor often has the benefit of having interviewed the customer, while the health professional often has experience and the capacity to research treatments of relevant conditions.

The view of Services Australia, supported by advice from the LB, is that one agency professional view is required for all opinions relevant to a JCA outcome.

This process relates to any situation where:

• A JCA report has been questioned by way of a referral to the HPAU and the outcome of the referral is a potentially significant change to a report, for example, HPAU advice on the JCA report is being requested by an ARO or a legal representative within the LB
• An Assessor has sought the opinion of the HPAU and the HPAU representative identifies their opinion is likely to differ from the Assessor's

If the Assessor is planning on seeking HPAU advice, especially if DSP may be cancelled, they should first consult with their Assistant Director to ensure the decision-making up to that point is correct and justified.

Before providing formal written advice on the matter, discussion between the relevant parties must have occurred.

Priority in this process is placed on an open non-defensive collegial discussion with a focus on the appropriate decision. Discussions begin at the level of Assessor and health professional before proceeding to any resolution process.

If consensus can be reached, the HPAU report should be completed which will then be reflected in the JCA. Any written advice from HPAU should not be scanned until a consensus view is obtained.

If a consensus cannot be reached, a brief case conference is organised. This is a solution-focussed negotiation leading to an agreed resolution with membership consisting of the HPAU representative managing the referral, Assessor, and the Assessment Services National Team representing the National Manager (NM) and providing secretarial duties for the case conference.

Parties in the case conference

Discuss the sources of evidence relating to the case and the relative 'weight' attributed to each piece:

• Review any inconsistencies between pieces of written evidences or with the customer's presentation
• Explore the known treatments and progress of the combination of the customer's medical conditions
• Discuss professional perspectives on the matter
• Explore sources of difference of opinion and what could lead to consensus

Parties may then agree on the matter at hand or decide to seek further medical information.

In some instances the matter may need to be escalated to senior or expert staff including staff from HPAU.

The outcome of the case conference is a written report indicating the consensus opinion.

The written report is copied to all parties to the case conference and to the Assessment Services Quality Team mailbox to be included in the Issues Management Register.

The written report from the HPAU is then finalised and provided to the referrer and scanned to the customer's record. The Assessor's report should reflect the agreed view on the matter and the rationale. The written report will not make reference to any disagreement, but record the parties' outcome and the consensus outcome.

If a consensus view is not achieved after escalation to the Director HPAU and/or Assessment Services Director, the case must be referred to the National Team via the Assessment Services Quality Team mailbox.

The national team will review the matter, liaise with the Director of the HPAU and Director of Assessment Services and make a final recommendation regarding the outcome for the NM to sign off. This will result in a report being prepared indicating the Assessment Services one professional view for scanning to the customer's record. The written report will not make reference to any disagreement, but record the parties outcome and the consensus outcome.