Elective surgery services policy

Guidelines for providing non-emergency surgical treatments to injured workers.

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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:

Definitions

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. 

Guidelines

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?

WorkSafe Victoria acknowledges that waiting for a decision to be made about a surgery request can be an anxious time. Where possible the agent will aim to advise you of an outcome within 10 days of receiving the request. However, within 28 days, the majority of surgery requests will be:

  • approved
  • denied
  • or more information will be required to make a decision (for example information from your treating health practitioner, the surgeon, an independent medical examiner or other medical consultant)

Due to the nature and complexity of some elective surgery requests the agent may require information from more than one source. This may add to the time it takes the agent to make a decision about the elective surgery request.

There are a few things that you and your treating practitioners can do to reduce the timeframe it may take for a decision to be made.

These include:

  • encouraging your surgeon to clearly outline in their request
    • the need for your surgery and how it is related to your work injury
    • outcomes of treatments that have been tried to date
    • expected outcomes of proposed surgery
  • ensure that relevant imaging results have been forwarded to the agent
  • providing relevant details to your managing agent about
    • relevant pre-existing conditions
    • prior treatment of relevant pre-existing conditions
    • the outcomes of these treatments
    • the healthcare professionals you saw in relation to the pre-existing injury

Your agent can explain the particular information that it requires to make a decision about the elective surgery that has been requested for you.

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

Related information