Occupational therapy services guidelines

The provision of equipment and related services

These guidelines are in line with the Workplace Injury Rehabilitation and Compensation Act 2013 (WIRC Act) and the Accident Compensation Act 1985.

WorkSafe will have regard to these guidelines when making decisions for the provision of occupational therapy services to people who have an accepted claim under the Victorian Workers Compensation Scheme.

These guidelines also apply when a person is entitled to provisional payments on a claim that includes a mental injury.

Throughout these guidelines, any reference to WorkSafe also includes WorkSafe’s agents and self-insurers.

This policy must be read with the following:

Occupational therapy services

WorkSafe can fund occupational therapy services to assist people to effectively recover from workplace injuries and safely return to work and life.

Occupational therapists (OT) can make an important contribution to improving the independence and return to work outcomes of workers.

OT services take 2 forms:

• treatment
• assessment.

What we can pay for

WorkSafe can pay the reasonable costs of occupational therapy services a person needs as a result of a work-related injury or illness under Victorian workers compensation legislation.

WorkSafe can also pay for the reasonable costs of occupational therapy for people who are entitled to provisional payments that include a mental injury.

The treatment or service must meet the following criteria.

• Be clinically justified, safe and effective.
• Be likely to achieve measurable improvement in a person’s functioning.
• Promote progress toward a person’s functional independence, participation and self-management.
• Be for rehabilitation purposes for a work-related injury only.
• Be delivered in line with the clinical framework.
• Be performed by a clinician registered by WorkSafe to provide occupational therapy services.

WorkSafe will periodically review a person’s entitlement to occupational therapy services to make sure treatment and services remain reasonable, clinically justified, outcome focused and payable under the legislation.

Occupational therapy assessment services WorkSafe will pay for

OTs may undertake assessments to review a worker's need for:

• household help
• equipment items
• attendant care support
• home modifications
• car modifications, if provided by an accredited Vic Roads assessor or equivalent.

OT delivering hospital-based inpatient/outpatient services

An OT employed or contracted by a hospital registered with WorkSafe may determine personal and household services and/or equipment items are required to facilitate the safe discharge of a worker from a hospital, or to increase their functional independence as they transition back to the community. The recommendations made by this OT can be accepted by the agent up to 12 weeks following discharge from care.

In these instances, a further OT assessment is not required on discharge to the community unless the worker’s circumstances have changed or the assessment did not consider specific requirements. It is also not necessary that a separate request for the services and/or equipment be made by a medical practitioner. This is because of the level of oversight medical practitioners have over a worker’s care whilst they are in a hospital setting.

Services we will not pay for

Under the Victorian workers compensation legislation, WorkSafe cannot pay for the following occupational therapy services.

• Services that are not required as a result of a worker’s accepted injury or illness.
• Services for a person other than the person with an accepted claim.
• Services that are not a reasonable cost as determined in accordance with the Victorian workers compensation legislation.
• Services provided outside of Australia without prior approval from WorkSafe.

Under WorkSafe’s determination of reasonable cost, WorkSafe will not pay for costs relating to the following.

• Treatment or assessment services provided by a health professional not registered and approved to provide occupational therapy services by WorkSafe.
• Treatment or services provided by telephone or other non face-to-face mediums that do not align with WorkSafe's telehealth policy.
• More than one initial consultation by the same provider or clinic unless exceptional circumstances apply. For example, hospital admission, or significant time has passed since the injured worker last received treatment.
• More than one treatment consultation a day for the same worker.
• Consumable prostheses, aides, and appliances used in the course of the consultation.
• Pharmacy items such as creams and gels supplied by THPs.
• Fees associated with cancellation or non-attendance.
• Treatment, services, prostheses, or equipment where there is no National Health and Medical Research Council level 1, or level 2 evidence of safety and efficacy.

How much we can pay

WorkSafe will pay for services in line with our fee schedules.

Sometimes there is a difference between what a provider charges and what WorkSafe will pay as the reasonable cost. If the provider charges more than what WorkSafe will pay, workers will need to pay the difference. In this instance, WorkSafe recommend the provider advise the worker prior to providing any services.

Who can provide these services

Occupational therapy services are delivered by providers who are approved and registered with WorkSafe to provide these services.

WorkSafe will only fund occupational therapy services delivered by providers that hold the requisite insurance coverage to deliver occupational therapy services.

Service delivery expectations

WorkSafe expects that all providers delivering occupational therapy services as part of the Victorian workers compensation scheme follow the below principles.

• Provide culturally safe and respectful services.
  • Protect the person’s human rights and report any concerns of abuse, neglect or discrimination to an appropriate regulatory or complaints body.
  • Support the person to maximise their independence, promote recovery and self-advocacy.

WorkSafe also expects that any treatment provided is reasonable, clinically justified, outcome focused, and in line with the Clinical Framework.

WorkSafe has reporting and engagement expectations for all providers delivering occupational therapy services to workers. WorkSafe expects providers to communicate, collaborate and provide information to WorkSafe and other relevant parties as required.

For example:

• Providers should work with treating health practitioners or other providers, such as medical practitioners to enable the most appropriate treatment and assessment.
• Providers should work with occupational rehabilitation providers, treating health practitioners and employers in relation to return to work and other tasks such as household cleaning and gardening.

Providers are required to comply with the requirements set out in these guidelines and in the Application for registration to provide services to workers.

If a provider does not meet these requirements or WorkSafe has concerns about the provider’s conduct or services delivered, WorkSafe may take appropriate action in accordance with the legislation.

Occupational therapy treatment expectations

After treatment has commenced, the OT must submit an Allied Health Recovery Management Plan (AHRMP) to the managing agent by the fifth consultation.

WorkSafe registered allied health practitioners are also expected to communicate and collaborate with other parties involved in the worker's support team to facilitate continuity of care and return to work.

Return to Work Case Conferences (RTWCC) bring together the worker, referring medical practitioner, employer, WorkSafe agent, occupational rehabilitation provider, and other relevant parties. They can be used to discuss the worker's capacity, any barriers affecting recovery, set goals, and agree on timeframes for recovery at, or return to, work.

Typically, a RTWCC will be requested by an agent or the occupational rehabilitation consultant however, a treating health practitioner can request a case conference by contacting the agent or the occupational rehabilitation consultant directly. RTWCCs will be remunerated as outlined in the occupational therapy services fee schedule.

Occupational therapy assessment expectations

All occupational therapy assessments are to take a reablement focus, focussing on types of assistance required to assist a worker to maximise their independence.

Certain types of assessments, such as occupational therapy driving assessments, may require specific credentialing. An occupational therapist should only accept referrals to conduct an assessment where they have appropriate expertise and knowledge of relevant WorkSafe policy.

Where available, it is expected that WorkSafe’s templates will be used to complete assessments.

When assessing workers for cleaning and gardening services and adaptive household equipment, the Household help services needs assessment (HHSNA) form must be used. All sections of the WorkSafe household help services needs assessment (HHSNA) form should be completed.

OTs will be asked to complete the following.

• A comprehensive functional assessment specific to the referral.
• Consider the expected and reasonable contribution of other household members.
• Contact the worker’s treating medical practitioner and/or therapy team. This could include the certifying practitioner, a physiotherapist or a psychologist etc.

OTs should discuss the recovery and services plan with the worker and any relevant parties, such as their case manager.

OTs should refer to household help services needs assessment (HHSNA) support material for expectations and support on conducting household help services needs assessments.

OTs prescribing equipment must comply with relevant WorkSafe policy and ensure no conflict of interest exists when prescribing items to injured workers.

Required information for agents

Referral requirements

WorkSafe considers occupational therapy a referred service. Occupational therapy services must be referred by a medical practitioner and approved by the agent before treatment commences.

Invoicing requirements

All services must be invoiced in line with WorkSafe's Occupational Therapy Services fee schedule.

For further information, refer to instructions for invoicing WorkSafe.

Unpaid or returned invoices

Concerns about unpaid or returned invoices should be directed to the agent case manager. Unresolved queries can be escalated by submitting an online complaint form.

Agent processing times

The agent will advise the outcome of a request for payment within 10 working days, or they may request extra information before making a decision.

If extra information is requested, the agent will confirm the request outcome within 10 working days of receiving the extra information.

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.