Medical practitioner services guidelines

What WorkSafe will pay for

WorkSafe Victoria (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 these guidelines, other WorkSafe policies or the Medical service reimbursement rates.

These guidelines must be read with the:

• Medicare Benefits Schedule (MBS)
• relevant WorkSafe policies
• Medical service reimbursement rates
• information on reimbursement of medical services.

In these guidelines, 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).

WorkSafe can pay the following.

• The reasonable costs of treatment and services provided by a medical practitioner to a worker where required for an accepted workers compensation claim for work-related injury or illness.
• The reasonable costs of treatment and services provided by a medical practitioner for workers entitled to provisional payments on a claim that includes a mental injury. Eligible Victorian volunteers are also entitled to provisional payments.
• 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 Medical service reimbursement rates information document.
• Medical reports that are authorised or requested by an agent and provided by a medical practitioner including Treating health practitioner (THP) reports requested by an agent as specified in the THP reports policy.
• Medical practitioner participation in return to work (RTW) activities (RTW Case Conferences, phone calls with employer, worksite visits) as specified in the Guide for general practitioners and the medical services – medical practitioner return to work activities fee schedule.
• Invoices that meet WorkSafe's instructions for invoicing WorkSafe.

Work-related injury

All references to 'work-related injury' in these guidelines may also apply to workers who are entitled to provisional payments on a claim that includes a mental injury.

Definitions

• Medical service includes attendance, examination or treatment of any kind by a medical practitioner in accordance with Victorian workers compensation legislation (the legislation).
• GP or medical practitioner RTW Case Conference is a meeting organised and coordinated by a WorkSafe agent (agent), approved occupational rehabilitation (OR) provider or the certifying GP or medical practitioner to improve communication and a worker's RTW outcomes. It includes those involved in the RTW process, the worker, certifying GP (or medical specialist or psychiatrist), 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 by video conference.
• GP RTW phone call is a phone consultation between a certifying GP and a 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 a worker's place of employment to discuss RTW opportunities with the employer, the worker and/or approved OR provider. These visits are agreed to by the employer and a report from the GP is not required.

General guidelines for medical practitioners

WorkSafe expectations for the delivery of medical services

WorkSafe expects medical practitioners providing services to workers as part of the Victorian Workers Compensation Scheme to integrate the principles of the Clinical framework for the delivery of health services (Clinical framework) into their daily practice.

The Clinical framework is based on the following principles.

1. Measure and demonstrate the effectiveness of treatment.
2. Adopt a biopsychosocial approach.
3. Empower the person to manage their injury.
4. Implement goals focused on optimising function, participation and return to work.
5. Base treatment on best available research evidence.

Medical practitioner 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 a worker stay at or return to work. WorkSafe can pay for GPs to complete the following.

• Organise, coordinate and participate in a RTW case conference.
• Engage in a phone call with an employer to discuss RTW.
• Conduct a worksite visit.
• Use their consultation time to communicate with the worker about staying at or returning to work.

Services WorkSafe will not pay for

WorkSafe will not pay for the following.

• 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. 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 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 phone calls and phone consultations (except for GP RTW phone calls) between providers and workers and between other providers, including hospitals that do not align with WorkSafe's telehealth policy.
• Telehealth services when telehealth codes are not included in the medical service reimbursement rates.
• Treatment or services provided by phone or other non-face to face mediums that do not align with WorkSafe's telehealth policy.
• Multiple consultations on a single day with the same worker without clinical justification and period of time between consultation.
• Billing of multiple claims on the same day, when service is provided as a single service. If there are multiple claims, in principle, it should be billed to the most active claim.
• Invoices for issue of certificate of capacity independent of or in addition to a consultation fee.
• Services provided outside of Australia without prior approval from the agent.
• Treatment provided to members of the immediate family of the medical practitioner.

Medical practitioners do not require a WorkSafe provider number

WorkSafe has adopted the Medicare Australia provider numbers and registration details for medical practitioners.

Payment for medical services outside Australia

Medical practitioners outside Australia must be lawfully qualified in that country for the services in question. The agent must have:

• accepted liability for the claim, or
• confirmed the worker is entitled to provisional payments, and
• provided prior approval of the services to be provided outside Australia.

Referrals 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 
• Podiatry

However, WorkSafe can pay only for the reasonable costs of services provided by some allied healthcare providers or personal and household services if there is a written request or referral for these services from a medical practitioner.

These services include:

• acupuncture
• attendant care
• dietetics
• exercise physiology
• household help
• naturopathy
• occupational therapy
• outreach
• psychology
• remedial massage
• social work
• speech pathology
• gym and swim programs.

Disclosing medical information about a worker

WorkSafe seeks to collect only health information about the 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 a 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 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.

Reports

WorkSafe can fund providers for the completion of RFIs when requested by WorkSafe to assist in: 

• determining a worker's eligibility for entitlements
• reviewing a worker's ongoing medical and like services
• the management of a worker’s rehabilitation and return to work
• any other purpose necessary for managing a claim

Medical reports may also be requested from the Workplace Injury Commission (WIC), the Medical Panel and other legal representatives in accordance with dispute resolution processes under the legislation.

Medication and pharmacy items

WorkSafe, either directly or through one of its authorised agents, can pay the reasonable costs of medications and other pharmacy items that meet the following requirements.

• Required as a result of a work-related injury or illness.
• Prescribed by a registered medical practitioner or registered dentist.
• Dispensed by a registered pharmacist.
• Provided in accordance with the Pharmaceutical Benefits Scheme (PBS).
• Provided in accordance with WorkSafe’s Pharmacy policy.

WorkSafe will review and consider paying the reasonable costs of non-PBS privately prescribed medications where they are clinically appropriate for the work-related injury or illness and there is no readily available alternative on the PBS.

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, and
• 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.

Prior approval for medical services

Prior approval from the agent is required for elective surgical procedures including implantable pain therapy and prosthetic items.

Surgical Procedures

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 as outlined in Medical service reimbursement rates information document.

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 2 or more operations performed on a patient on the one occasion should be calculated using the following rules.

• 100% for the item with the greatest WorkSafe fee
• plus 75% of each other item

Fractures and dislocations

For the treatment of fractures and dislocations, the fees for 2 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 the 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.

Hospital operation

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
• 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
• Signature/authorisation

Note: 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).

Invoicing information WorkSafe requires from medical practitioners

For details on the information required when submitting invoices for medical services, refer to the Instructions for invoicing WorkSafe.

WorkSafe's Billing review program

For details on WorkSafe's billing review program, refer to the Billing review program: medical providers.

Suspended from providing services to WorkSafe clients

If WorkSafe gives notice to a provider that they are suspended from providing services to WorkSafe clients, WorkSafe will notify the Australian Health Practitioner Regulation Agency or other relevant professional body that regulates the provider, and Medicare Australia of the suspension and the grounds on which the suspension has been issued.