Billing Review Program: Dental providers

Information for dental providers

Why TAC and WorkSafe have a provider billing review

WorkSafe conducts periodic reviews of payments made to providers, including dental providers, through its Billing Review Program (BRP). The primary focus of the program is to ensure that payments made to dental providers are appropriate and comply with the TAC and WorkSafe policies and fee schedules.

WorkSafe may review payments made to dental providers for services to injured workers at any time.

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

The WorkSafe BRP aims to ensure that payments made to dental providers are appropriate. Clinical advice is obtained by WorkSafe when completing billing reviews.

WorkSafe's Clinical Panel comprises medical, allied healthcare and dental practitioners who review the services provided to injured workers. These reviews aim to ensure that these services are clinically justified and improve health and return-to-work outcomes.

How WorkSafe requests information for reviews

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

This section of the legislation provides the authority for the requested patient health information and documents to be supplied to WorkSafe. As such, a dental provider is not required to obtain patient consent to release the required patient information and documents under these provisions.

How TAC and WorkSafe notify providers about reviews

WorkSafe will contact providers about a review before a visit, and arrange a time to collect the required information and documents. If copies are not available at the time of collection, they can be taken and copied before being returned to you in an agreed timeframe. WorkSafe may also contact other parties, including hospitals and other health facilities, to obtain information and documents, to help with the billing review.

WorkSafe aims to communicate and obtain requested information and documentation from dental providers in a co-operative way.

In some circumstances, the TAC and WorkSafe also have 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 documentation obtained by the TAC and WorkSafe will not be used by to manage TAC client or injured worker claims.

Confidentiality and secure storage of patient information

WorkSafe is required to 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 dental providers as part of the BRP is managed in accordance with WorkSafe privacy policies. This information will not be will not be placed on claims files.

What is considered in a review

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

When conducting reviews, WorkSafe considers:

• billing data
• client or worker information
• clinical records
• attendance records
• other supporting information and documents
• relevant policies and fee schedules

WorkSafe relies on clinical advice from appropriately qualified peer clinicians during a billing review.

Who do providers deal with during reviews

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

How long will the review process take

The review process can take up to several months to complete, depending on the time taken to collect the required information and the number of other reviews being completed. 

WorkSafe aims to clarify any issues as part of the review. WorkSafe also encourages providers to communicate with either organisation or their professional bodies if they have any queries.

What happens at the end of my review

At the end of a review, WorkSafe will communicate with the dental provider about the outcome of the review. Potential outcomes include one or more of the following:

• no further action taken
• a request for explanation
• a request for reimbursement of any incorrect/inappropriate payments
• referral/notification to the relevant regulatory body
• referral for investigation

Where appropriate, WorkSafe will provide practical and constructive advice about how to comply with a relevant policy or billing rule.

Where professional conduct issues are identified, WorkSafe may also refer issues identified to the Australia Health Practitioners Regulation Agency (AHPRA) for review and suspend payments to you for services provided to injured workers pending the outcome of the AHPRA review. Before a referral or notification to the AHPRA, WorkSafe will give the dental provider an opportunity to respond to the issues identified. Any response received will be considered when determining if a referral to the AHPRA 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 as a matter of course.

If during a payment reconciliation or self-audit, providers discover any billing errors or incorrect billing practices about services provided to injured workers, they can contact WorkSafe’s Advisory Service.