What WorkSafe will pay for
The WorkSafe Agent (the agent) can pay the reasonable costs of elective surgery when required as a result of a work-related injury or illness when the service is provided by a registered medical practitioner in accordance with Victorian workers compensation legislation.
WorkSafe adopts the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions for surgical services provided by suitably qualified medical practitioners.
This policy must be read in conjunction with the following documents:
What is elective surgery?
In this policy, elective surgery is clinically necessary, non-emergency surgical treatment (including surgical procedures) performed by a registered medical practitioner.
What can the agent pay for in relation to elective surgery?
The agent can pay the reasonable costs of:
- surgical services that:
- have an item number in the MBS
- are clinically justified
- are required as a result of a work-related injury or illness
- are requested and performed by a registered medical practitioner
- hospital and theatre fees in accordance with the relevant and current WorkSafe private hospital fee schedule
- surgically implanted prosthetic items as listed on the current Prostheses List published by the Department of Health and Ageing (DoHA) and in accordance with the Surgically Implanted Prostheses Policy
What information does the agent require to consider paying for elective surgery?
Written approval from the agent is required prior to elective surgery being performed.
To facilitate a timely decision on the request and to ensure the most appropriate services are provided to the worker, the agent requires a written request from the medical practitioner that includes:
- the MBS item number(s) associated with the specific elective surgery request
- name and claim number of the worker
- name of medical practitioner performing the elective surgery
- brief description of the specific elective surgery requested
- clinical indication for the elective surgery and the relationship between the surgery and the work-related injury or illness
- anticipated prosthesis details, if required. If this is a gap-permitted or unlisted prosthesis, written clinical justification is required
- refer to WorkSafe's Surgically implanted prostheses policy
The agent will accept the above information in a letter from a surgeon to a third party, for example, the referring GP. This should be provided to the agent with notification from the surgeon clearly starting that this is a request for funding.
When will I receive a response from the Agent?
Within 10 working days of receiving the elective surgery request, the Agent will advise whether:
- the request has been approved
- the request has been denied
- further information is required to make a decision
Where further information is required, the Agent will advise whether the elective surgery request has been approved or denied within 10 working days of receiving the additional information.
What invoicing information does the Agent require from medical practitioners?
It is a WorkSafe requirement that each item billed must be supported by adequate detail in the hospital operation report.
For further details on the information required when submitting invoices to the Agent for elective surgery, please refer to Instructions for invoicing WorkSafe.
What fees are payable for elective surgery?
The Agent can pay the reasonable costs of elective surgery in accordance with the:
- Reimbursement rates for medical services
- Private hospital fee schedules
- Victorian Department of Health's fees Manual
- minimum price of surgically implanted prosthetic items as listed on the prostheses list
In relation to elective surgery what will the Agent not pay for?
The Agent will not pay for:
- services that are not in accordance with the MBS items, explanations, definitions, rules and conditions for services provided by medical practitioners unless otherwise specified by WorkSafe
- the provision of hospital operation reports as these reports form part of the surgical service and are generated at the time of the surgical procedure
- services for a condition that existed before the work-related injury or illness or that is not a direct result of the work-related injury or illness
- treatment or services where there is no National Health and Medical Research Council level 1 or 2 evidence that the treatment or service is safe and effective. Refer to the Non-established, New or Emerging Treatments and Services Policy
- services that are of no clear benefit to the worker
- non-attendance fees where a worker failed to attend
- the cost of telephone calls and telephone consultations between providers and workers, and between other providers, including hospitals
- treatment/services subcontracted to a non-registered provider
- services provided outside of Australia without prior approval from the agent
- treatment provided to members of the immediate family of the medical practitioner
- invoices that do not meet WorkSafe's Invoicing guidelines for medical practitioners