What WorkSafe can pay for
The WorkSafe Agent (the Agent) can pay the reasonable costs of public hospital services where required as a result of a work-related injury or illness under Victorian workers' compensation legislation (the legislation).
Fees for services performed within a public hospital will be based on the Department of Health and Human Services (DHHS) Fees and Charges for Acute Health Services in Victoria as published in the DHS Fees Manual. Refer to www.health.vic.gov.au/feesman for an outline of the agreed rates payable.
This policy must be read in conjunction with:
- Medical practitioner policy
- Pharmacy policy
What can the Agent pay for in relation to public hospital services?
The Agent can pay the reasonable costs of public hospital services in an in-patient or outpatient setting, for acute or rehabilitation purposes, where the services are:
- Required as a result of the work-related injury or illness
- Reasonable, necessary or appropriate in the circumstances
- Clinically justified, safe and effective
- In accordance with the WorkSafe's guidelines; and
- Payable by WorkSafe under the Victorian workers' compensation legislation.
The Agent can pay for in-patient public hospitalservices where an injured worker meets the criteriafor admission as outlined by the DHHS. For further information on the Victorian Hospital Admission Policy, on the VicHealth website (www.health.vic.gov.au).
The public hospital in-patient bed fee covers the cost of all treatment, services and items provided to an inpatient. This includes, but is not limited to:
- All accommodation costs
- All required surgical and medical procedures including theatre fees
- Required radiology, pathology and diagnostic procedures
- All nursing and allied health services
- Dietary requirements including meals, nasogastric feeds and dietary supplements
- Copy of admission information, operation report, discharge summary
- Aids and equipment used during the hospital stay and for a period of 30 days following discharge
- All pharmacy items
- Attendant and personal care support
- Treatment or services provided by third party providers i.e. non-hospital employed staff
- Consumable or disposable products.
The Agent can pay the reasonable costs of the following public hospital services in addition to the bed fee:
- Medical services provided by a medical practitioner with the right of private practice
- Prescribed work-related discharge medication(s) supplied within 48 hours of discharge
- Injured worker to receive work-related injury or illness medical services at another facility (e.g. ambulance, patient transport service or taxi).
Inpatient Acute Care Services
The Agent can pay for an injured worker's acute inpatient stay in a public hospital, as a result of a work-related injury or illness, by funding an inpatient episode fee.
Acute care services include treatment for an injury or illness including surgery, treatment to relieve the symptoms of injury or illness and diagnostic or therapeutic procedures.
The Agent uses a casemix classification funding system to pay for acute inpatient accounts at Victorian Public hospitals.
Casemix funding is based on a patient episode that is cost-weighted according to its Diagnostic Related Group (DRG) and length of stay. DRG's classify patients with similar clinical conditions and similar levels of resource use by the hospitals.
For further details surrounding DHHS funding policies and guidelines, refer to www.health.vic.gov.au/pfg.
Hospital in the Home (HITH)
Hospital in the Home (HITH) provides hospital inpatient care in a patient's home. A HITH admission can take place following or instead of a period of acute inpatient care.
Injured workers receiving HITH will be regarded as acute admitted patients of the hospital and must fulfil the same criteria for admission as any other patient. For further information, refer to the DHHS Victorian Hospital Admission Policy.
Prior approval is advised prior to commencing this service.
Inpatient Rehabilitation Services
The Agent can pay for the cost of inpatient rehabilitation services in public hospitals when related to the work-related injury or illness.
Rehabilitation care includes multi-disciplinary programs designed to significantly improve or restore the function of an injured worker who has undergone an acute or exacerbated injury or illness.
Inpatient rehabilitation treatment must be provided within a designated rehabilitation unit. Inpatient rehabilitation services are paid on a per diem basis in accordance with the relevant inpatient rehabilitation classification. Inpatient rehabilitation classifications are defined by DHHS and include:
- Level 1 rehabilitation services
- Level 2 rehabilitation services
- Level 1 spinal services
- Level 2 spinal services
- Alfred Health ABI rehabilitation centre.
The Agent can pay for inpatient mental health care for an injured worker who, as a result of their work-related injury or illness, requires admission into one of the following inpatient mental health services:
- Adult Acute: Provides short-term inpatient management and treatment during an acute phase of mental illness on a voluntary or involuntary basis for patients. Treatment is provided until they have recovered enough to return to the community safely, with a focus on reducing symptoms and promoting recovery. Units are located within acute general hospitals.
- Aged Acute: Provides short-term assessment and treatment for older persons aged over 65 with acute symptoms of mental illness. Patients receive treatment until they are able to return to the community safely. These services occur within an aged care facility or general hospital.
- Child and Adolescent Mental Health Services (CAMHS): Acute Provides short-term assessment and/or treatment for young people (0-18 years) experiencing severe emotional disturbance. Treatment may include crisis assessment case management, family therapy, parent support, individual therapy, group therapy and medication based treatments where deemed necessary. Patients receive assessment and/or care within an acute general hospital until they have recovered enough to return to the community safely.
- Acute Specialist: Provides specialised assessment, treatment and consultancy services for injured workers with significant impairment due to acute symptoms of a major mental illness. Common diagnoses include neuropsychiatric conditions such as eating disorders, schizophrenia, personality disorder or dual diagnosis that result in self-harm or inappropriate behaviour towards others.
- Adult Extended Care: Provides longer term inpatient treatment and rehabilitation for patients aged up to 65 years experiencing severe symptoms of mental illness together with significant disturbances which inhibit their capacity to safely live in the community Mental health services are paid for on a per diem basis based upon the hospitals location within the Melbourne metropolitan area or within rural Victoria.
Attendant care requirements
The inpatient bed fee (all inpatient classifications) covers the cost of all care needs required by an injured worker. The Agent will not pay for separate attendant care services while the injured worker is an inpatient of the hospital. In the event that a public hospital deems that attendant care is essential for the effective management of an injured worker, then the hospital is responsible for the provision of the service and the associated costs.
The Agent can consider the payment of the reasonable costs associated with training public hospital clinical staff prior to the inpatient admission of an injured worker to ensure their specific care needs are met. Prior written approval is required from the Agent before training is to commence.
During an inpatient episode it may be recognised that training of attendant carers by clinical/allied health staff is required to ensure a safe and effective discharge. Training costs are deemed inclusive of the inpatient fee and will not be paid for by the Agent.
Overnight Bed Leave
An injured worker may need to undertake a short period of bed leave to assist with the transition from hospital to the community. A bed leave fee is not payable by the Agent and the injured worker is not considered to be an inpatient for the period of their leave. The Agent must be notified by the hospital when a worker undertakes overnight bed leave.
The reasonable cost of travel (e.g. taxi) can be considered for an injured worker to undertake hospital approved overnight bed leave. Refer to the WorkSafe Policy For Travel Expenses For Medical And Hospital Services for further information.
Public hospitals, in partnership with the Agent, have a responsibility to facilitate the safe and effective discharge of injured workers. Early notification of the expected discharge date and any anticipated ongoing care needs by the public hospital assists in facilitating safe and effective discharge.
Once discharged, a copy of the injured worker's discharge summary may be requested. The discharge summary should be provided to the Agent within five days of the request. The cost of a discharge summary is included in the bed fee.
All aids and equipment required by an injured worker whilst an inpatient of the hospital are included in the bed fee. Upon discharge, Victorian public hospitals are responsible for the organisation and cost of aids, equipment and domiciliary oxygen to facilitate a safe and effective discharge for a period of 30 days post discharge.
It is expected that items will be purchased rather than hired if it will be more cost effective for the duration required. After 30 days post-discharge the Agent is responsible for the provision of aids and equipment required as a result of the /workrelated injury or illness. Victorian public hospitals must contact the Agent to determine whether any current hire arrangements will continue.
The two exceptions to this equipment guideline include:
- Continence equipment
- Highly customised equipment
The Agent can pay for continence products such as catheters, consumables and other related products required as a result of a work-related injury or illness upon the injured worker's discharge.
Highly customised equipment provided for admitted injured workers with a permanent or long term disability can be paid by the Agent upon discharge. This includes prostheses such as artificial limbs or an electric wheelchair.
Prior approval is required for the provision of highly customised equipment.
Where an injured worker uses equipment provided by the Agent prior to admission, the Agent will continue to provide those aids and equipment upon discharge where required.
The Agent can pay the reasonable costs of public hospital outpatient services required for a worker as a result of their work-related injury or illness.
Outpatient fees will be paid on a fee-or-service basis in accordance with the fees and item numbers listed by the DHHS. Refer to www.health.vic.gov.au/feesman for an outline of the agreed rates payable.
Medical services provided by salaried medical practitioners to outpatients may be charged on a fee-for-service basis in accordance with the Medicare Benefit Schedule (MBS).
The Agent can pay an Emergency Department (ED) attendance fee when the services have been provided by a hospital approved to provide emergency services by the DHHS.
Care provided in an ED is not an admitted service. Where an injured worker's entire hospital care is provided in the ED, it is not considered a hospital inpatient admission, irrespective of whether a criterion for admission is met.
The ED attendance fee is payable to cover the services, materials and administrative costs of an injured worker being treated within an ED. The attendance fee is not payable if the injured worker requires an inpatient admission.
If the injured worker was seen at another hospital prior to being transferred to the admitting hospital, the initial referring hospital may be paid an ED attendance fee. An ED attendance fee can only be paid once per claim. A subsequent charge by the same hospital will only be paid if accompanied by documentation from the hospital explaining the circumstances for emergency treatment. Medical treatment provided by registered medical practitioners can be charged on a fee-for-service basis in accordance with the WorkSafe Reimbursement Rates for Medical Services.
The Agent can pay the reasonable costs of outpatient rehabilitation services required for an injured worker as a result of their work-related injury or illness.
Outpatient rehabilitation for injured workers must be time limited, goal focused and multi-disciplinary in nature.
Spinal Community Integration Services (SCIS)
The Victorian Spinal Cord Service (Austin Health) offers a Spinal Community Integration Service (SCIS) designed to meet the transition and community integration needs of injured workers with a Spinal Cord Injury (SCI). The primary functions of the service are to:
- Facilitate an injured worker's transition from hospital and reintegration into the community
- Provide a coordinated approach for injured workers to receive trans-disciplinary support and education.
SCIS commences while an injured worker is an inpatient at either the Royal Talbot Rehabilitation Centre or the Caulfield Hospital and continues for an average of 12 months post discharge into the community. Prior approval is not required for a/n injured worker to access the service.
SCIS runs concurrently with an injured worker's existing inpatient rehabilitation or community rehabilitation services. The service is designed to maximise independence, self-management and integration in the community after a spinal cord injury.
SCIS provides specialist expertise related to the holistic management of an injured worker after a spinal cord injury through collaboration with hospital and community providers. Injured workers will continue to access existing community rehabilitation and disability providers through local community services.
Freedom of Information Requests
Where the Agent makes a Freedom of information (FOI) request in relation to accessing the medical records of an injured worker, a public hospital may charge the Agent for the reasonable cost incurred in making those arrangements as prescribed in the Victorian Freedom of Information Act 1982.
Medical Specialist Reports
The Agent can pay for medical specialist/practitioner reports where the treating medical specialist/practitioner raises the charges under their own private practice and in accordance with the WorkSafe Policy for Treating Health Practitioner Reports.
Hospital Reports or Medical Officer Reports
A Hospital Report is a report prepared by clerical staff on behalf of the public hospital's medical officer and provides a summary of the medical records.
A Medical Officer's Report is a report prepared by the public hospital's medical officer.
A legal practitioner can make a request for reimbursement of costs for medical and hospital reports obtained in support of their injured worker's claim for compensation. Prior to requesting a medical or hospital report, legal practitioners are encouraged to check with the Agent whether a report has already been obtained to avoid unnecessary duplication.
Reimbursement for the cost of obtaining a medical report from a public hospital is in accordance with the fees listed by the Department of Health at www.health.vic.gov.au/feesman.
- Public Hospital fees and charges are set by the Victorian DHHS and reimbursed according to the agreed Fees and Charges for Acute Health Services in Victoria available at http://health.vic.gov.au/feesman/fees4.htm.
- The Agent expects that Public Hospitals provide agreed invoice information including:
- DRG/ICD/Date of admission/discharge etc.
- injured worker name and claim number
- Admitted patient VICDRG statement
ICD-10AM - invoices for inpatient treatment and services must quote a primary International Classification of Diseases, 10th Revision, Australian Modification code. The code required is that which best describes the injury or illness being treated by the hospital. Other procedure codes may be quoted in addition to the primary code.
Payment of Interstate Public Hospital Accounts Public
Hospital fees and charges are reimbursed according to the gazetted rates for compensable patients made known to the public and publicised by each State or Territory Health Department.
For more information regarding the applicable rates please refer to:
- New South Wales - http://www.health.nsw.gov.au/
- Queensland - http://www.health.qld.gov.au/
- South Australia - http://www.sahealth.sa.gov.au/
- Tasmania - http://www.dhhs.tas.gov.au/
- Western Australia http://www.health.wa.gov.au/
- Australian Capital Territory - http://www.health.act.gov.au/
- Northern Territory http://www.health.nt.gov.au/
In relation to public hospital services, what won’t the Agent pay for?
The Agent will not pay for:
- Hospital services for a person other than the injured worker
- Non-attendance fees where a worker failed to attend
- Hospital services provided outside Australia without prior written approval from the Agent
- Treatment and services unrelated to the work-related injury or illness Treatment or services provided by telephone or other non face to face mediums where not provided for in the Medicare Benefits Schedule
- Telephone calls and telephone consultations between providers and injured workers, and between other providers, including hospitals
- Incidental items that occur as part of an injured worker's inpatient admission, e.g. telephone calls, television hire, general toiletries, newspapers, visitor's meals, etc.
- Treatment or services where there is no objective evidence that a treatment or service is safe and effective
- Treatment or service where liability has not been accepted.
Contact the referring Agent oremail [email protected].