Technical Support and Escalations - Medicare Compensation Recovery 011-15040000

MCR uses the Technical Support Model, which focuses on developing Service Officer capability and promoting self-sufficiency to assist with resolving queries or problems.

Training and consolidation activities promote and support self-sufficiency, helping to reduce the dependence on technical support. Service Officers can access Operational Blueprint and other endorsed online tools to assist with developing capability.

Service Officers must escalate work items to the relevant tier of support when:

• they cannot resolve an issue themselves
• there are specific instructions or delegations in place

MCR Technical Support Model

Tier 0 - Self Sufficiency:

• Service Officers self-research using Operational Blueprint and other endorsed resources
• Team members network with colleagues to share advice and problem solve

Tier 1 - Accredited staff:

• Tier 1 staff are APS4 Service Officers accredited to provide technical support to their peers
• Service Officers request Tier 1 support when they are unable to resolve an issue at Tier 0

Tier 2 - Service Support Officer (SSO5) and Tier 3 - Program Management (PM):

• Tier 2 support is provided by SSO5s (APS5) from the Service Delivery Operational Support team
• Tier 3 support is provided by PM

If Tier 1 accredited staff are unable to resolve a support query, they will:

• tell the Service Officer to escalate to Tier 2 or Tier 3, depending on the scenario or necessary delegation, or
• escalate the query directly

All staff can escalate directly to Tier 2 or Tier 3 when:

• directed to by Operational Blueprint or other endorsed resources
• an activity requires specific delegation, such as higher-level business process or policy escalations

If an SSO5 determines that a higher level of delegation is needed for a decision they will escalate the claim (including all relevant details) to PM requesting a decision.

The SSO5 and PM:

• consider the relevant legislation, policies and customer’s individual circumstances when assessing an escalation. The final decision is made relevant to the intent of the legislation and policies
• add case notes with the details for Service Delivery to action
• will not contact the customer unless there is a specific reason for customer contact

Service Officers should ask for technical support when:

• they have tried to research themselves and did not find the answer
• there are potential system issues
• Operational Blueprint or other communications direct them to refer to a higher tier of support
• they are considering a decision using the REFLECT model

Service Officers should not contact technical support regarding:

• mySupport and access issues
• customers requesting to talk to a supervisor about customer service issues, such as:
• inappropriate staff behaviour
• time frames
• help with de-escalating a customer's aggressive behaviour. See Enquiries and authenticating a customer - Medicare Compensation Recovery
• requesting a support officer to contact a customer on the Service Officer’s behalf, unless there is a critical reason

The role of the support tiers is to build Service Officer capability by providing:

• advice and guidance on complex issues
• assistance with interpreting rules, policies and procedures
• reassurance and support that helps to strengthen decision making

Service Officers use available resources to support their decision making, including:

• Operational Blueprint
• Endorsed communications and resources available on the Medicare Compensation Recovery SharePoint
• Technical Sessions
• Training materials
• Network of support:
• peers
• broader operational team
• team leaders
• subject matter experts

Service Officers can make evidence-based decisions within their delegation using the REFLECT model. When they are unable to resolve an issue using self-sufficiency, the Service Officer can request support from Tier 1.

See Document Assessment - Medicare Compensation Recovery

Service Officers must lodge all peer support contact requests using the Tier 1 Support Tool.

Tier 1 phone support can be given for urgent assistance with a complex call where the customer is on the phone.

Escalations to all Tiers must have case notes that include:

• the question - clearly outline the request for the receiver to action
• the background - summarize any relevant details, timeline or evidence relating to the question
• recommendations - any recommendations for the receiver to consider
• all related Work Item Numbers (WINs) and cases on the referral form

Tier 1 - Role

Tier 1 Support must maintain an impartial view and follow all legislation and policies. They may communicate with a range of internal and external stakeholders and provide advice that maintains consistent delivery of program services.

The role of Medicare Compensation Recovery Tier 1 Support is to:

• guide, educate and assist Service Officers
• build Service Officer capability and identify learning opportunities to help staff become self-reliant when resolving similar enquiries
• provide real-time support to Service Officers when on a call with a customer, if appropriate
• take-over escalated calls from customers about technical issues (this does not include complaints or behaviour issues). For example, if a customer wants to speak with a technical expert for an in-depth explanation. See Enquiries and authenticating a customer - Medicare Compensation Recovery
• escalate, or direct the Service Officer to escalate the enquiry to Tier 2 or 3, as per the Decision Making model
• identify:
• potential issues in the Medicare Compensation Recovery System and escalate accordingly
• training needs and learning opportunities

Tier 1 Support aim to complete all requests in a timely manner. Urgent requests and Service Officers on a call with a customer are prioritised. All other requests can take up to two working days during busy periods.

Tier 1 - Responsibility

It is the responsibility of Tier 1 accredited staff to:

• respond to Level 1 complaints received in the Customer Feedback Tool
• complete random and targeted quality checking
• maintain a current knowledge base
• facilitate Technical Sessions in collaboration with leadership, Quality, Program Management and the Operational Support team
• identify areas for improvement to policy/procedures, and provide appropriate feedback
• assist leadership with other tasks on behalf of Service Delivery including reviews of policy/procedures
• provide a high-level of customer service
• process work at a Service Delivery level when needed

The Resources page contains contact details for the Tier 1 Support phone number and a link to the Tier 1 Support tool.

All Tier 1 Support enquiry responses:

• generate an email to the Service Officer to review and action
• populate a report available to Medicare Compensation Recovery leadership
• must adhere to the Australian Public Service (APS) Code of Conduct. Immediately report any breach of these guidelines to a Team Leader.

Tier 1 support response is used by:

• Service Officers to review and discuss response emails during coaching or as part of their learning and development
• Operational Support and Team Leaders to:
• access data about Tier 1 Support contacts at an individual, team and site level
• help identify trends for coaching and support

Editing of Tier 1 Support tool requests

A Service Officer may be asked to edit the request to:

• remove sensitive information or inappropriate comments
• provide more information
• change details when the request is
• submitted as On Phone and the call has ended
• marked Urgent however is not considered an urgent request (or vice versa)

The Tier 1 Support tool shows all existing Tier 1 Support requests submitted by the Service Officer.

SSO5 and PM assist with decisions above the delegation of Tier 1 Support, for example:

• removing services for uncompensated injuries where medical evidence has been submitted for the decision
• exceptional or out of scope requests and enquiries, including giving an accurate interpretation of policies to make sure the correct course of action is taken

A Service Officer can directly escalate a work item to:

• SSO5 using the Escalate to SSO5 button on the Evaluate screen when they need:
• help to determine if a compensation claim is notifiable or not notifiable
• help or advice from an SSO5 (or above)
• a review of decision
• a care cost breakdown
• an amendment request where there is evidence of a judgment or settlement
• PM using the Escalate to PM button on the Evaluate screen when they:
• need assistance with complex issues, sensitive claims or legal advice
• need a policy decision
• have a care cost amendment or removal request
• have a claim that is identified as a potential Bulk Payment Agreement (BPA)
• have amendments over 2 years

Escalated Enquiry cases (automatic or manual) are assigned to staff members with the appropriate MCRS skill tag through Work Optimiser - Health (WO).

Service Officers must not use the transfer assignment function in MCRS.

If the ‘Escalate to’ buttons are not showing, see Table 5

See the Resources page for escalation reasons including which level to use when escalating a work item.

Automatic Escalations

A work item requiring a decision by another Service Officer with the appropriate MCRS skill tag is automatically transferred when there is:

• an identified care costs and assessment needed
• a Notice of judgment or settlement (NOJS) refund or debt over $50,000
• a Notice of reimbursement arrangement (NORA) refund or debt over $50,000
• a specific delegation needed to make a decision
• an increase in the Notice of charge (NOC) amount

As Subject Matter Experts (SMEs), Tier 1 staff are responsible for the management of Medicare Compensation Recovery (MCR) complaints. This includes receiving, assessing, and actioning complaints in accordance with agency protocols and service standards.

Customer complaints regarding MCR can be received:

• on the agency’s Feedback and Complaints line
• via a general business queue
• on an outbound call
• in a service centre
• in writing
• online

All MCR customer complaints are recorded in the Customer Feedback Tool (CFT) and are actioned as follows:

• Level 1 complaints - received through Work Optimiser- Health are assessed by Tier 1 Support
• Level 2 complaints - assessed by Level 2 Complaints Officers who liaise with Program Management to resolve any complaints that:
• could not be resolved at Level 1, or
• meet the customer complaint escalation reasons

See Managing complaints and feedback for more details on the different types of complaints and how they are managed.

Compensation

Not all ‘compensation’ references in a complaint are for MCR. The agency also pays compensation under other schemes, for example:

• Scheme for Compensation for Detriment caused by Defective Administration
• COVID-19 Vaccine Claims Scheme

Careful assessment of each complaint is needed to determine if the compensation complaint is for MCR.

Complaints that are not applicable to MCR must be reassigned by a Team Leader through Operations Management Division.

For more details see:

• Process page > Table 4
• Level 1 - Manage customer complaints and feedback
• Recording customer complaints and feedback in the Customer Feedback Tool
• Level 1 - Online customer feedback

Decision making

All MCR Service Officers can make evidence-based decisions within their delegation.

Every decision must be:

• legal
• ethical
• evidence-based
• aligned with the core principles in the Services Australia REFLECT model
• included in case notes as per business requirements

See Document Assessment - Medicare Compensation Recovery and Claim Management - Medicare Compensation Recovery for more details.

Priority processing escalation requests

Priority processing requests may be considered in certain situations. For example:

• financial hardship
• an injured person has a limited life expectancy
• an injured person is a minor before the court
• court mandated requirement
• ministerial complaints
• other sensitive claims

A sensitive indicator is added to the claim to easily identify circumstances that need priority processing.

When a caller requests priority processing, Service Officers must:

• tell the customer that claims are processed in date order, unless the claim meets the priority processing standards
• ask the caller for details about the reason for the priority processing request
• review the correspondence on file, and
• give the caller details of any outstanding items needed to process the request

Only trained staff can action priority process claims. For more details, including the escalation process, see

• Table 3 in Enquiries and authenticating a customer - Medicare Compensation Recovery for steps on priority processing from a phone enquiry
• Process page > Table 2 for details on escalating an enquiry case to a trained Service Officer
• Claim management - Medicare Compensation Recovery for a list of sensitive indicators.

Service Offers not trained in allocated work type

When a Service Officer is allocated a work item for a work type they are not trained in, they must unassign the work item using Proficiency Raise in Workload Manager (WLM). For example, the work item is statement documents that need judgment or settlement processing and the service officer is not skilled in this type of work.

See Process page > Table 5 for more details about unassigning out of scope work items.