Billing Review Program: Medical providers

Information for medical providers

Why WorkSafe has a providing billing review

WorkSafe conducts periodic reviews of payments made to providers for medical and allied health services provided to injured workers through the Billing Review Program (BRP). The primary focus of the program is to ensure 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

The WorkSafe Billing Review Program focuses on ensuring that payments made to medical providers are appropriate and in accordance with the explanations, definitions and rules of the Medicare Benefits Schedule (MBS), and/or WorkSafe policies and the Reimbursement Rates for Medical Services booklet.

The WorkSafe Clinical Panel, comprising medical and allied healthcare practitioners, reviews the services provided to injured workers to ensure they are clinically justified and are achieving health and return to work outcomes.

How WorkSafe notifies providers about reviews

When seeking information and documents directly from a medical 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 provides the authority for the requested patient health information and documents to be supplied to WorkSafe. As such, a medical provider is not required to obtain patient consent to release the required patient information and documents under these provisions.

WorkSafe will contact you about a review before a visit and arrange a time to collect the requested information and documents. If copies are not available at the time of collection, documents can be taken to be copied and returned to you 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 seeks to communicate and obtain requested information and documentation from medical 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 documentation obtained by WorkSafe is not used to manage injured workers’ claims.

Confidentiality and secure storage of patient information

WorkSafe appreciates any concerns medical providers may have with respect to the security of confidential 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 medical providers as part of the Billing Review Program is 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 providers are appropriate and comply with the MBS and/or WorkSafe policies and fee schedules.

When completing a review, WorkSafe considers:

• billing data
• worker information
• clinical records
• attendance records
• other supporting information and documents
• relevant policies and fee schedules
• the medical benefits schedule

WorkSafe relies on clinical advice from appropriately qualified peer clinicians 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 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 reviews being completed.

WorkSafe strives to communicate and clarify any issues identified as part of the review as soon as possible. WorkSafe also encourages medical providers to communicate with either organisation or their professional bodies if they have any queries.

What happens at the end of the review

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

• no further action taken
• a request for explanation
• request for reimbursement of any incorrect/inappropriate payments
• referral/notification to the Australian Health Practitioner Regulation Agency (AHPRA) and / or
• referral for investigation

When 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 the issues to AHPRA for review. WorkSafe can also suspend payments to you during the AHPRA review.

Before referring an issue to the AHPRA, WorkSafe will give the medical provider a chance to respond to the issues identified. WorkSafe will consider a provider’s response to decide if a referral to AHPRA is appropriate.

Payment reconciliation and self-audit

WorkSafe encourages all providers to reconcile payments received with their invoices and to review their billing practices relating to WorkSafe claims as a matter of course.

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