Information for Occupational Rehabilitation (OR) providers
Why WorkSafe has a provider billing review
WorkSafe conducts periodic reviews of payments made to providers for medical, allied health and OR services. The primary focus of our Billing Review Program (BRP) is to ensure that payments made to these providers are appropriate and comply with WorkSafe policies and fee schedules.
Information WorkSafe may request for reviews
When seeking information and documents directly from an OR provider as part of the BRP, WorkSafe may formally notify you of a requirement for worker information and records and documents made by you pursuant to section 552 of the Workplace Injury Rehabilitation and Compensation Act 2013.
This section provides the authority for the supply of the requested information and documents to WorkSafe. As such, an OR provider is not required to obtain consent from injured workers to release the 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 OR provider's Agreement for provision of occupational rehabilitation services when requesting information and documents.
How WorkSafe notifies providers about reviews
WorkSafe will contact providers about a review before a visit and arrange a time to collect the requested information and documents. These documents will be returned to providers within an agreed timeframe. WorkSafe may also contact other parties, including hospitals and other health facilities, to obtain information and documentation, to help with the billing review.
WorkSafe seeks to communicate and obtain requested information and documentation from providers in a co-operative way.
In some circumstances occupational rehabilitation, 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 for any other purpose than the billing review and will not be used to manage 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.
Information collected from providers as part of the Billing Review Program is managed in accordance with WorkSafe privacy policies, and is not placed on claim files.
What is considered in a review
A WorkSafe billing review focuses on ensuring that payments made to OR rehabilitation providers are appropriate and comply with WorkSafe policies, fee schedules and any relevant agreements.
When conducting reviews, WorkSafe considers:
- billing data
- worker information
- clinical records
- relevant policies and fee schedules
- provisions of the Agreement for occupational rehabilitation services
WorkSafe obtains and relies upon clinical advice from appropriately qualified peers.
Who providers deal with during reviews
If payments made to you are under review, you may receive a request 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 undertaken at any one time.
WorkSafe endeavours to communicate and clarify any issues identified as part of the review. WorkSafe also encourages OR providers to communicate with WorkSafe or their professional bodies if they have any queries
What happens at the end of the review
At the conclusion of the review, WorkSafe will communicate with you about the outcome of the review.
Potential outcomes include one or more of the following:
- no further action being taken
- an explanation being required
- reimbursement of any incorrect/inappropriate payments
- suspension or termination of your Agreement for the provision of OR services with WorkSafe
- referral for further investigation
When appropriate, WorkSafe will provide providers with practical and constructive advice about how to comply with the relevant policy and billing rules. Responses from providers will be considered when decided the next course of action.
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 self-audit, you discover any billing errors or incorrect billing practices in relation to services provided to injured workers, you should contact the relevant WorkSafe insurers, who will work with you to address any issues and provide advice about resolving errors.
If you have any specific queries about WorkSafe policies and fee schedules, contact the WorkSafe Advisory Service.