What WorkSafe will pay for
WorkSafe Victoria (WorkSafe) can pay the reasonable costs of medical services provided by a medical practitioner to a worker where required as a result of a work-related injury or illness.
WorkSafe adopts the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions for services provided by medical practitioners. When invoicing for medical services, medical practitioners are expected to adhere to the MBS rules unless otherwise specified by WorkSafe in this policy, other WorkSafe policies or the Reimbursement Rates for Medical Services booklet.
This policy must be read in conjunction with the:
- Medicare Benefits Schedule (MBS);
- relevant WorkSafe policies outlined in the Reasonable Medical and Like Services section of the our website; and
- Reimbursement Rates for Medical Services booklet.
In this policy, a medical practitioner means a person registered under the Health Practitioner Regulation National Law Act 2009 to practise in the medical profession (other than a student) and includes a general practitioner (GP).
General Guidelines for Medical Practitioners
In this policy a:
- medical service includes attendance, examination or treatment of any kind by a medical practitioner in accordance with Victorian workers compensation legislation (the legislation).
- GP Return to Work Case Conference is a meeting organised and coordinated by a WorkSafe Agent (Agent), approved occupational rehabilitation (OR) provider or the certifying GP to improve communication and a worker's Return to Work (RTW) outcomes. It includes those involved in the RTW process, the injured worker, certifying GP, employer, Agent and approved OR provider, meeting to discuss return to work barriers and opportunities. Although it is preferred that case conferences are held face to face, they can also be held over the telephone or via video.
- GP Return to Work Phone Call is a phone consultation between a certifying GP and an injured worker's employer. The purpose of the call is to discuss ways to support a worker stay at, or return to, work. The worker is invited to participate or give consent for the call.
- GP Worksite Visit is a certifying GP visiting an injured worker's place of employment to discuss RTW opportunities with the employer, the injured worker and/or approved OR provider. These visits are agreed to by the employer and a report from the GP is not required.
When can WorkSafe pay for services provided by medical practitioners?
WorkSafe can pay for:
- medical services in accordance with the fees listed in the Reimbursement Rates for Medical Services booklet
- medical services provided by a medical practitioner that have an item number in the MBS and are listed in the Reimbursement Rates for Medical Services booklet
- medical services using the Australian Medical Association (AMA) item numbers where there is a corresponding MBS item number and the MBS item number is listed in the Reimbursement Rates for Medical Services booklet
- medical reports that are authorised or requested by an Agent and provided by a medical practitioner
- GP participation in Return to Work Activities (RTW Case Conferences, Phone Calls with an Employer, Worksite Visits)
- services directly provided by that medical practitioner.
GP Return to Work Activities
WorkSafe recognises the important role that GPs play in the return to work process and encourages GPs to communicate with other stakeholders, such as the employer, Agent and/or approved OR provider in helping an injured worker stay at or get back to work. WorkSafe can pay for GPs to:
- organise, coordinate and participate in a RTW Case Conference
- engage in a phone call with an employer to discuss RTW
- conduct a Worksite Visit; and
- use their consultation time to communicate with the injured worker about getting back to , or staying at work.
For more information, refer to the General Practitioner Participation in Return to Work Activities Information Sheet and the GP Return to Work Activities Fee Schedule.
Magnetic Resonance Imaging
Prior approval is not required for an Agent to pay the reasonable costs of Magnetic Resonance Imaging (MRI) when:
- referred by a medical practitioner
- required to investigate symptoms or signs that have directly arisen from a work-related injury or illness.
Payment of MRI services as a diagnostic test by the Agent does not constitute acceptance of ongoing liability for any subsequent procedures or treatment requested as a result of the diagnostic findings.
When will WorkSafe not pay for services provided by medical practitioners?
WorkSafe will not pay for:
- services that are not in accordance with the MBS 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 workrelated injury or illness or that is not a direct result of the work-related injury or illness
- treatment or services where there is no objective evidence that a treatment or service is safe and effective
- 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 (except for GP RTW Phone Calls) 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 WorkSafe Agent
- treatment provided to members of the immediate family of the medical practitioner, and
- invoices that do not meet WorkSafe Invoicing Guidelines for Medical Practitioners
Is prior approval required for medical services?
Prior approval from the Agent is required for elective surgical procedures including implantable pain therapy and prosthetic items.
Please see the Elective Surgery policy, the Implantable Pain Therapy policy or the Prosthesis Policy for Private Hospitals for more information.
Does a medical practitioner require a WorkSafe provider number to provide medical services?
No, WorkSafe has adopted the Medicare Australia provider numbers and registration details for medical practitioners.
Are medical practitioners able to disclose medical information about an injured worker?
WorkSafe seeks only to collect health information about the injured worker that relates to the medical services provided for their work-related injury or illness.
Under the legislation and relevant privacy legislation, WorkSafe and its Agents are permitted to collect personal and health information about an injured worker from medical practitioners. The worker's claim form contains an Authority to Release Medical Information signed by the worker. This authorises medical practitioners to give personal and health information relating to medical services and hospital services provided to the worker in connection with the worker's claim to WorkSafe and its Agents.
A Collection Statement on the form advises the injured worker that WorkSafe and its Agents may collect information about them from their medical practitioners and others, and that this information may be used to assist WorkSafe and its Agents to better manage claims.
When can WorkSafe pay for medical services outside Australia?
Medical practitioners outside Australia must be lawfully qualified in that country for the services in question and the WorkSafe Agent must have accepted liability for and provided prior approval of the services to be provided outside Australia.
Can a medical practitioner refer a worker for allied health and other services?
A medical practitioner referral or request is not required for the following allied health services: chiropractic, dental, osteopathy, optometry, physiotherapy and podiatry.
However, WorkSafe can only pay for the reasonable costs of services provided by some allied healthcare providers or personal and household services if there is a written request/referral for these services from a medical practitioner.
Some of these services include: acupuncture, attendant care, dietetics, exercise physiology, household help, loss and grief counselling, naturopathy, occupational therapy, pharmacy, psychology, remedial massage, social work, speech pathology and gym & swim programs.
For payment of surgical services, WorkSafe has adopted the MBS explanations, definitions, rules and conditions for services provided by medical practitioners with the following exceptions:
Multiple Operations – Orthopaedic procedures
For orthopaedic operations set out in Group T8, subgroup 15 of the MBS (other than fractures and dislocations), the fees for two or more operations, performed on a patient on the one occasion should be calculated using the following rules:
- 100 per cent for the item with the greatest WorkSafe fee; plus 75 per cent of each other item.
Fractures and Dislocations
For the treatment of fractures and dislocations, the fees for two or more operations performed on a patient on the one occasion should be calculated using the following rules:
- For multiple dislocations or fractures requiring an operative or manipulative procedure, the fee for each dislocation or fracture shall be 100% of the WorkSafe fee.
- For multiple dislocations or fractures where the second or subsequent conditions do not require operative or manipulative treatment, the fee for the second and each subsequent procedure shall be 75% of the WorkSafe fee.
- When fractures or dislocations are associated with a compound (open) wound, an additional fee of 50% of the fracture or dislocation fee shall apply. The additional 50% applies only to the fracture or dislocation fee and does not apply to the fees for any other procedures that may be performed during the surgery. The medical practitioner must state on their invoice 'Open' or 'Compound' next to the procedure item number.
- Except where otherwise specified by WorkSafe, the fee for a fracture-dislocation to the same site shall be the fee for the fracture or dislocation, whichever is the greater, plus 50% of the WorkSafe fee for the lesser procedure.
Report For any surgical procedures provided in a public or private hospital operating theatre, the principal surgeon must provide the hospital operation report generated at the time of the surgical procedure, when submitting their invoice.
Hospital operation reports will be accepted if they are either the:
- exact copy of the hospital operation report in the patient's medical file, or
- a dictated hospital operation report from the surgeon.
The following is a list of details that are expected to be included in a hospital operation report:
- Patient's name and date of birth
- Date of surgery
- Date of report
- Name of principal surgeon
- Name of assistants
- Description of all services*
- Appropriate item numbers
*The description of all services performed needs to be adequately detailed to explain the procedure and the items invoiced. For example, the description should include the approach, procedure, closure, any prostheses used and the side and site of the procedure, particularly when more than one procedure is being performed.
A hospital operation report is not required for surgical procedures that are provided outside of a hospital operating theatre (such as 'in rooms' or emergency).
What information is required for an elective surgery request?
WorkSafe Agents require a request from the surgeon for elective surgery.
Please refer to the Elective Surgery Policy for further details.
What invoicing information does WorkSafe require from medical practitioners?
For details on the information required when submitting invoices for medical services, refer to the Invoicing Guidelines for Medical Practitioners.
What is WorkSafe's Billing Review Program?
For details on WorkSafe's billing review program, refer to the Billing Review Program: Information for Medical Practitioners.
Suspended from providing services to WorkSafe clients
If WorkSafe gives notice to a provider advising them that they are suspended from providing services to WorkSafe clients, WorkSafe will notify the Australian Health Practitioner Regulation Agency and Medicare Australia of the suspension and the grounds on which the suspension has been issued.