WCB Procedures

Client inquiry resolution

Procedure summary

Published On

May 7, 2024

Purpose

To ensure consistent handling of worker and employer inquiries, concerns and complaints.

Description

This process applies when a worker or employer expresses a concern to a Workers’ Compensation Board-Alberta (WCB) decision maker about the handling of a claim, a treatment they have received during an examination, or any other issue that is of concern to them, including a concern that they have about the decision maker assigned to their claim.

Resolving client concerns will sometimes require the involvement of multiple levels of WCB management. The following process description and procedure contains information regarding the decision maker’s actions as well as other WCB employees to provide a complete picture of how these concerns are handled by WCB.

The procedure starts with a WCB employee receiving a concern or complaint. The decision maker assesses the concern or complaint, works to resolve the concern, and ensures the worker or employer is aware of their rights in their interactions with the WCB and how WCB conducts itself to make sure those rights are recognized. These rights are outlined in the Code of Rights and Conduct. The decision maker documents related information about the concern or complaint.

When the decision maker is unable to resolve the concern, depending on if the complaint is related to a decision or is a service issue, the supervisor and/or manager coordinate as appropriate to determine how to address worker or employer concerns or complaints. When the concern is about a specific claim decision that was made, and the concern is not resolved, the review and appeal process will be explained to the client by the decision maker and/or supervisor. Managers may become involved if the concern is a service issue that is not resolved by the supervisor.

When complaints are sent directly to the Board of Directors or WCB senior management, they are forwarded to the supervisor and manager of the decision maker handling the claim. When complaints are sent to the CEO or Board of Directors an Action Request is created to monitor the response.

Key information

When a client has a concern about a WCB decision or service, staff attempt to resolve the concern collaboratively with the client wherever possible. They work to ensure the client feels that their concern has been fully explored and understood, and that solutions to address the root cause of the issue are found. Staff also ensure that WCB decisions regarding the resolution of client concerns are clearly explained to the client and documented as needed.

The decision maker is the first line of contact for all verbal and written communication about a claim; in most cases the concern can be resolved by the decision maker. However, when a client is dissatisfied with the outcome of a decision (or does not feel comfortable speaking with the decision maker about a service concern) they may reach out to a supervisor. This is the standard escalation process for responding to client concerns; each level of review (decision maker and supervisor) follows the same steps to attempt to resolve the concern.

If the concern is a service issue, the manager may also become involved. In rare cases when the complaint about service delivery cannot be resolved through this process it may be forwarded to the Fair Process Review Centre. (Additional information can also be found in the WCB Alberta Client and Staff Collaboration section of the WCB website and the Code of Rights and Conduct.)

If a client’s behaviour is abusive or threatening, follow the 10-3 Critical Incidents procedure.

If a communication strategy is needed to ensure safe, respectful, effective communication with a client, follow the internal Procedure 20.4 - Alerts.

Detailed business procedure

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1. Assess the nature of the client's concern(s) and contact them to discuss a resolution Decision maker Review and assess the nature of the client’s concern(s) and determine: Whether the concern is related to a decision or a service issue. Whether the issue has been raised before, and if so, how it was addressed. What outcome the client might be looking for. Contact the client to acknowledge and discuss their concern(s) and explore possible resolution(s). Ask questions to ensure a clear understanding of their concern(s); be respectful and express WCB’s interest in working with them to resolve the issue(s). If the root cause of the concern(s) can be addressed, attempt to do so and explain these intentions to the client. If the concern(s) can be resolved without escalation to a supervisor, send the appropriate letter summarizing the client's concern and how it was addressed. If the concern involves an adverse decision include information about the decision review process in the letter. If the client wishes to speak with a supervisor about their concern(s) (including if they want to request a new decision maker), provide them with the supervisor’s contact information. Ensure that the client understands the WCB client resolution process and confirm that they have all information required to work through the process. Note: The decision maker is always the first level of contact to attempt to resolve a client’s concern. If the complaint was escalated to a supervisor, monitor the claim for their review and recommendation(s) and implement the recommendation(s) as required. When the concern is about a physician or treatment provider, inquiries from a college or association or a request for a new claim owner, refer to the individual section in the Types of requests or complaints section below.	Administrative tasks Document the discussion in a file note (Contact/Claimant Contact or Employer Contact) including a summary of the client’s concern or request and the steps taken to attempt to resolve or escalate the complaint. Follow the appropriate procedure for the claim circumstance, if applicable: 10-3 Critical Incidents Internal Procedure 20.4 - Alerts WCB Alberta Client and Staff Collaboration section of the WCB website Send the appropriate letter: Acknowledge Service Complaint (GE000D) Claimant Custom (CL000A)
2. Assess the client's concern and how it was addressed by the decision maker Supervisor or manager Review the details of the client’s concern(s) and any discussions or actions the decision maker or other WCB party has taken to date to find resolution. Discuss the concern(s) with the decision maker and consider if the client’s rights have been impacted by the action that initiated the complaint. Contact the client to acknowledge and discuss their concern(s) and explore possible resolution(s). Ask questions to ensure a clear understanding of their concern(s); be respectful and express WCB’s interest in working with them to resolve the issue(s). If the root cause of the concern(s) can be addressed, attempt to do so and explain these intentions to the client. Discuss the steps WCB will take to address the concern(s), and when a follow up meeting will occur, if required. Arrange a teleconference with the client and decision maker if helpful to resolve the concern. When the concern involves changing the decision maker, consider the guidelines for making that decision (see the Request to change the claim owner section). Note: When a concern is escalated to a supervisor, they will complete Steps 2 and 3 to attempt to resolve the complaint. If the client is not satisfied with the outcome, the concern can be escalated to the manager who will also complete Steps 2 and 3 to attempt to find resolution.	Administrative tasks Document the discussion in a file note (Contact/Claimant Contact or Employer Contact), including a summary of the client’s concern or request, the steps taken to attempt to resolve or escalate the concern and any other information the decision maker might need to ensure continuity. Follow the appropriate procedure for the claim circumstance, if applicable: 10-3 Critical Incidents Internal Procedure 20.4 - Alerts WCB Alberta Client and Staff Collaboration section of the WCB website
3. Communicate the proposed resolution with the relevant parties and document the decision Supervisor or manager Communicate the proposed resolution and ensure that all relevant parties understand how the outcome plan was determined and the Code of Rights and Conduct requirements for interacting with clients, if appropriate. See the WCB Alberta Client and Staff Collaboration section of the WCB website for more information. Contact the client again (if required) to discuss the actions taken to resolve their concern(s). Send the appropriate letter summarizing the concern(s) and documenting the discussion(s) and decision(s). If the concern: Is an adverse decision, the letter should explain the decision review process. Is a service issue, the letter should explain how the concern has been or will be resolved. Has previously been addressed by a manager, the letter should: Confirm the concern has been addressed in previous correspondence. Explain that further responses will be sent if new information is received (advise that new information will be reviewed and actioned by the decision maker). The manager may advise the client they can request a review of a service through the Fair Process Review Center	Administrative tasks Document the discussion in a file note (Contact/Claimant Contact or Employer Contact). Send the appropriate letter: Acknowledge Service Complaint (GE000D) Worker Request CM Change (CL054E) Employer Request CM Change (IN054A) If the client shared their concern(s) with the media or a government official, send a copy of the response letter to Corporate Communications and Legislative Relations, and to the CEO’s office if the complaint was sent or copied to the CEO.

Types of requests or complaints

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Request to change a claim owner WCB supervisors determine when a change in claim owner is appropriate. The impact of service issues on the relationship between the claim owner and the client and the degree to which it hinders the ongoing management of the claim must be considered. A supervisor will consider reassignment of a decision maker if there has been a breach of customer service standards or client trust. A new decision maker may also be assigned if it serves to protect a client or WCB staff, or if a conflict of interest has been identified by a client or claim owner. If the claim owner requests the claim be reassigned, the supervisor reviews their basis for the request and determines if a reassignment would be beneficial for the management of the claim.	Administrative tasks If approving the request to change the decision maker, add an eCO Participant Alert: Select Disability Management in the Usage Type field and Communication in the Alert Type field. Input the following in the Description field: A request for new case manager has been approved by <supervisor's name>. This claim, and future claims, are not to be assigned to <employee's name>.
Complaints about physicians Contact the client and discuss their concern(s) about a physician. Acknowledge and address their concerns and explain the role of the physician(s) involved. If the concern, can't be resolved, advise the worker to submit a written complaint addressed to the Medical Services manager. All written complaints about the professional conduct of a physician, quality of examination(s) or services provided by a physician are referred to a Medical Services manager. Note: The worker will receive a written response from the Medical Services manager registering the complaint and addressing the concern(s). If a satisfactory resolution cannot be reached, the worker may be advised to register a formal complaint with the College of Physicians and Surgeons.	Administrative tasks Document the details of the conversation in a file note (Contact/Claimant Contact).
Complaints about treatment providers (such as physiotherapist or chiropractor) A worker or employer may make a complaint about the professional conduct or quality of an examination or a treatment provider, such as a physiotherapist or chiropractor. Discuss their concern(s) and determine if the concern relates to a claim decision about treatment or entitlement or if it relates to the conduct of a treatment provider and/or the quality of the services received (for example, ergonomic assessments, physiotherapy treatments, etc.). Acknowledge and address their concern(s) and explain the role of the treatment provider. Send all complaints about a treatment provider’s conduct or quality of an exam, etc. to the health care consultant responsible for the treatment provider’s contract.	Administrative tasks Send an email to the appropriate health care consultant. Document the nature of the complaint, date it was received, and any other relevant information. The health care consultant will respond to the inquiry.
Inquiries from college or association A complaint to a college or association may be made by a worker, another college member or health professional. Part of the investigation by the institution may include sending a written request to WCB for further information. All inquiries that are from a professional regulatory body (e.g., Physiotherapy Alberta - College and Association, etc.) related to the service provider network, should be addressed by the specific health care consultant responsible for the contract. If the request from a College or Association involves access to documents only and there is no signed consent from the worker to release the information, the request should also be addressed by the health care consultant responsible for the contract.	Administrative tasks Send an email to the appropriate health care consultant. Document the nature of the inquiry, date the inquiry was received, and any other relevant information. The health care consultant will respond to the inquiry.
Practitioner declines to treat a WCB worker When a medical practitioner declines taking a WCB worker as a patient, refer the issue to the medical manager or designate describing the concerns, the practitioner's contact information and any other pertinent comments. The Medical Services manager will contact the practitioner to discuss the issue and attempt to resolve the concern. They will notify the decision maker if the practitioner is still not agreeable to see WCB clients as patients. When the practitioner does not agree to see the WCB worker as a patient, advise the worker to see another practitioner. Send a follow-up letter to the worker summarizing the issue and the recommendation to see another practitioner.	Administrative tasks Send a task to the Medical Services manager. Use the task name ‘Practitioner declines to treat a WCB worker’ and include the following in the task description box: Practitioner's name, Telephone number, Other relevant information such as reference to a medical file note, etc.). Send a Claimant Custom (CL000A) letter to the worker requesting they see another practitioner.
Client inquiries to the president, CEO, or board of directors Correspondence addressed directly to the president, CEO or board of directors, are assigned an action request number (even if other recipients have been copied on the letter). The action request is assigned to the appropriate person to respond to the inquiry or concern. An acknowledgement letter is sent with a date when the correspondent can expect a response. When the response letter is sent, ensure a copy of the letter along with the original correspondence outlining the concern is placed on the claim file.

Supporting references

Policies

Codes of rights and conduct

Workers’ Compensation Act

Applicable sections

Section 9.2- Code of rights and conduct
Section 23.1- Fairness review officer
Section 23.2- Powers of fairness review officer

General Regulation

Applicable sections

Related Legislation

Applicable sections

Compatibility Warning

WCB Procedures

Client inquiry resolution

Procedure summary

Detailed business procedure

Decision maker

Administrative tasks

Supervisor or manager

Administrative tasks

Supervisor or manager

Administrative tasks

Types of requests or complaints

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Supporting references

Policies

Workers’ Compensation Act

General Regulation

Related Legislation