What Role Does the TAC Clinical Panel Play in Determining Whether Your Surgery Is Paid For?

If you’ve been injured in a transport accident, you may be surprised to find that the Transport Accident Commission (TAC) don’t automatically agree to pay for all requested treatment. Sometimes the TAC need assistance from medical professionals to help them to decide whether treatment is reasonable and necessary. These medical professionals are known as the TAC Clinical Panel.

Knowing how the Clinical Panel works can help you, your treating doctors and other professionals navigate the system more effectively.

Who are the TAC Clinical Panel?

The TAC Clinical Panel is made up of allied health and medical professionals, including surgeons, general practitioners, psychiatrists, rehabilitation physicians, pain specialists, physiotherapists, occupational therapists, psychologists, speech pathologists, audiologists, nurses and other allied health practitioners.

All members should be practising clinicians from both public and private healthcare settings.. Their collective role is to provide clinical advice to TAC claims managers.

What does the Clinical Panel do?

The Clinical Panel’s primary function is supposed to be to give independent, evidence-based clinical advice to TAC claims managers. They do not make funding decisions. Instead, they are supposed to help ensure that treatment recommendations are clinically justified and aligned with best practice principles.

When reviewing a case, Clinical Panel Members may:

• Assess the effectiveness of current treatments and recovery progress;
• Discuss return-to-work capacity and certification issues;
• Clarify medical aspects of injuries or prognosis;
• Evaluate requests for new or ongoing treatments, surgery, medical interventions or pharmacotherapy; and
• Consider findings from independent medical examinations.

They may also engage directly with healthcare providers to discuss treatment approaches, manage complex recovery barriers and comment on the application of TAC’s Clinical Framework for the Delivery of Health Services.

How the Clinical Panel reviews surgery requests

When a surgeon requests TAC approval for surgery, the request may be referred to the Clinical Panel. Any referral should be made in line with the TAC Surgery Charter.

The Panel should then provide recommendations on whether the proposed surgery is:

1. Clinically appropriate (is the surgery suitable for the accident-related injuries and medical presentation?);
2. Justified (does it align with TAC principles such as improving function, supporting self-management and promoting return to health?); and
3. Evidence-based (is there strong clinical research supporting the likely benefits of the procedure?).

By evaluating these factors, the Clinical Panel ensures the TAC has expert clinical advice to make informed decisions.

The TAC makes the final decision

While the Panel provides advice, the TAC claims manager ultimately decides whether surgery is funded. This decision considers:

1. The Panel’s recommendations;
2. Reasonableness of cost; and
3. Overall recovery plan and treatment alternatives.

A recommendation from the Clinical Panel strengthens the case for surgery approval - but is not a guarantee. Legal guidance can help ensure your needs are clearly represented in this process.

Transport Accident Act is the paramount consideration

It is also worth noting that ultimately the TAC must make a decision in accordance with Section 60 of the Transport Accident Act which requires them to pay for reasonable treatment and reasonable fees. This legislative obligation trumps any TAC policies or frameworks and is always the critical factor in any decision concerning the funding of medical and like services.

How the Clinical Panel supports healthcare providers

The Clinical Panel is also set up to offer guidance to treating clinicians, including:

• Discussing optimal treatment options and recovery pathways;
• Supporting management of complex cases; and
• Sharing outcome measures to track and demonstrate treatment effectiveness.

This support is supposed to ensure that treatment is evidence-based, targeted to accident-related needs and aligned with TAC best practice principles.

However, treating clinicians should still always be making their own decision based on what they consider is in the best interests of the client and what treatment is required for the client’s accident-related injuries. The Clinical Panel is not a court, is not binding and should not be seeking to exert unnecessary influence over the clinician, who must make their own, independent and unbiased assessment of what treatment is required and whether it is linked to the transport accident related injuries.

Key takeaways for TAC clients

The TAC Clinical Panel is frequently utilised by TAC claims managers to assist them to make decisions. While the Panel provides advice, it does not make the final decision about whether surgery or other treatment is funded - that responsibility still rests with the TAC and must be made in accordance with Section 60 of the Transport Accident Act.

There has been a significant increase in the use of the Clinical Panel by TAC over the last 12 months, which has resulted in delays to some individuals. The overuse of the Clinical Panel by claims managers is being monitored by TAC.

An individual is entitled to access the Clinical Panel documents and these can be sought from their claims manager, by ROI (request of information) or FOI (freedom of information). Legal guidance can assist with obtaining these critical documents in order to evaluate the reasonableness of a TAC decision.

For injured Victorians, understanding the Clinical Panel process can help make the experience less confusing and more transparent. Having legal guidance throughout can also make a significant difference - ensuring that your case is properly presented, your treatment needs are clearly communicated and your recovery goals are fully represented.

Robinson Gill Lawyers’ specialist TAC team is uniquely positioned to assist with this process, offering expert support to help you navigate surgery approvals and achieve the best possible outcome in your recovery journey.