Billing Review Program: Allied health providers

Information for allied health providers

WorkSafe conducts periodic reviews of payments made to allied health services providers. The Billing Review Program (BRP) focuses on ensuring that payments made to medical and allied health providers are appropriate and comply with WorkSafe policies and fee schedules.

WorkSafe may review payments made to you for services provided to injured workers at any time.

Difference between the Billing Review Program (BRP) and reviews by the Clinical Panel

WorkSafe's Clinical Panel, comprising medical and allied healthcare providers, reviews the services provided to injured workers to ensure they are clinically justified, in line with the Clinical Framework for the Delivery of Health Services, and that services improve health and return to work outcomes.

Information WorkSafe may request for reviews

When seeking information and documents directly from an allied health provider as part of the BRP, WorkSafe may formally notify you of a requirement for patient health information and documents pursuant to section 552 of the Workplace Injury Rehabilitation Act 2013.

This section provides the authority for the supply of the requested patient health information and documents to WorkSafe. As such, an allied health provider is not required to obtain patient consent to release patient information and documents requested under this provision.

If you are a contracted provider, WorkSafe may in some circumstances, rely on the audit provisions contained in the relevant allied health provider’s services agreement when requesting information and documentation.

How WorkSafe notify providers about reviews

WorkSafe will contact providers about a review before a visit and arrange a time to collect the requested information and documents. Documents will be returned to providers within an agreed timeframe. WorkSafe may also contact other parties to obtain information and documentation, including hospitals and other health facilities, to help with the billing review.

WorkSafe aims to communicate and obtain requested information and documentation from allied health providers in a co-operative way. In some circumstances, WorkSafe also has the authority to inspect, examine or make extracts from, or copies of any information within premises that may be required to complete a billing review.

The information and documents we collect will only be used for the billing review, not to manage an injured worker's claim.

Confidentiality and secure storage of patient information

WorkSafe must comply with the Information Privacy Act 2000 (Vic), the Health Records Act 2001 (Vic) and the Information Privacy Principles and Health Privacy Principles set out in those Acts. Patient information collected from allied health providers as part of the Billing Review Program will not placed on claim files and is managed in accordance with WorkSafe privacy policies.

What is considered in a review

A WorkSafe billing review focuses on ensuring that payments made to medical and allied health providers are appropriate and comply with WorkSafe policies and fee schedules.

When conducting reviews, WorkSafe considers:

• billing data
• worker information
• clinical records
• relevant policies and fee schedules

WorkSafe obtains and relies on clinical advice from appropriately qualified peers during a billing review.

Who providers deal with during reviews

If payments made to you are under review, you may receive requests for information from a representative from WorkSafe’s Enforcement Group.

How long will the review process take

The review process can take up to several months, depending on the time taken to collect the required information and the number of reviews being undertaken at any one time. WorkSafe will clarify any issues identified as part of the review. Allied health providers can contact WorkSafe or their health professional bodies if they have any queries.

What happens at the end of the review

WorkSafe will confirm the outcome of the review with providers.

Potential outcomes include one or more of the following:

• no further action being taken
• a further explanation being required
• reimbursement of any incorrect/inappropriate payments
• referral to a relevant regulatory body (e.g. Australian Health Practitioner Regulation Agency - AHPRA), and/or
• referral for further investigation

Where appropriate, WorkSafe will offer providers practical and constructive advice about complying with relevant policies and billing rules.

When professional conduct issues are identified, WorkSafe may also refer the issues to the relevant regulatory body. WorkSafe can also suspend payments for services provided to injured workers pending the outcome of that further review.

Before referring an issue to the relevant regulatory body, WorkSafe will give the allied health provider a chance to respond to the issues identified. Any response received will be considered when determining if a referral to the relevant regulatory body is appropriate.

Payment reconciliation and self-audit

WorkSafe encourages all providers to reconcile payments with invoices and to review their billing practices relating to WorkSafe claims.

If during a self-audit you discover any billing errors or incorrect billing practices in relation to services provided to injured workers, you should contact WorkSafe's Advisory Service.