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SIRA workers compensation guide for medical practitioners

medical doctor and his team

Introduction

A worker with a workplace injury or illness is encouraged to choose their own doctor and this is often their usual general practitioner or family doctor. This guide is to help you understand your role as a medical practitioner in the NSW workers compensation system.

The doctor’s role is defined by workers compensation legislation and there are certain obligations you must meet. Your primary objective is to support the worker to optimise their recovery, generally achieved through recovery at work, clinical intervention and management.

Under the workers compensation system, your patient is referred to as a worker. This guide explains the roles of other people involved, who together provide a support team for the worker, including you, the employer, the insurance agent, approved workplace rehabilitation providers and allied treatment practitioners.

Advice and direction in this guide is based on a strong body of research and evidence about the health benefits of work, and how returning to work and where possible, recovering at work after an injury, can promote healing and facilitate recovery.

As the vast majority (more than 80 percent) of workers with an injury return to and recover at work within the first 13 weeks, this guide helps you to work with the support team to determine what the worker can do, rather than what they can’t.

We know that the longer a worker is away from work, the less likely they are of ever returning. Your role in assessing the worker’s capacity will help the worker and employer identify suitable tasks to enable recovery at work. This interaction is critical to preventing long term disability and bringing about the best possible outcome for the worker.

Most injured workers take little or no time off work. For those that do, the vast majority (more than 80%) return to and recover at work within the first 13 weeks.

Health benefits of work

There is good evidence that:

  • work is therapeutic and promotes recovery1
  • safe work is good for you physically, socially, and financially2, 3
  • time off work is often not medically necessary, and can delay recovery3
  • the longer a worker is off work the less likely they are to ever return to work4

The workers compensation system

The State Insurance Regulatory Authority (SIRA) is the government organisation responsible for regulating and administrating the NSW workers compensation system and is also the regulator for workplace health and safety in NSW.

The system comprises four types of insurance agents:

  1. The Workers Compensation Nominal Insurer is the single largest workers compensation insurer in NSW. The Nominal Insurer contracts scheme agents to manage policies and claims on its behalf.

    The five approved scheme agents are:

    • Allianz Australia Worker’s Compensation (NSW) Limited
    • CGU Workers Compensation (NSW) Limited
    • Employers Mutual NSW Limited
    • GIO General Limited
    • QBE Compensation (NSW) Limited

2. Treasury Managed Fund (TMF) – manages workers compensation, administration and financial liability for most public sector employers except those who are self-insurers.

3. Self-insurers – are employers approved by us to manage their own workers compensation claims.

4. Specialised insurers – hold a restricted licence to provide workers compensation insurance for a specific industry or class of business or employers.

Regardless of which type of insurance agent is involved, they all have an obligation to support employers, and workers in their recovery at work and manage claims to ensure they receive their entitlements.

SIRA certificate of capacity

Our certificate of capacity is the primary communication tool for the nominated treating doctor. It provides complete and accurate information to ensure the worker, insurance agent, employer and others involved in the worker’s recovery have a clear understanding of the worker’s needs.

Your recommendations on the certificate help the employer and worker to identify suitable work options. The more detailed information you provide, the easier it will be for the employer to identify and offer work that is a good match and facilitates safe recovery at work. There is comprehensive information on our website to assist you in completing the certificate.


Your role as the nominated treating doctor

While your usual role as a doctor involves assessing, diagnosing, treating and certifying patients, your role as a doctor in the workers compensation system also involves the following two responsibilities:

  • to support the worker to return to, and where possible to recover at work, through appropriate clinical intervention and management
  • to contribute to return to work and recover at work planning, in collaboration with the worker and other members of the support team - the insurance agent, employer, approved workplace rehabilitation provider and other treatment practitioners.

This diagram shows the steps involved for managing an injured worker's treatment under the NSW workers compensation scheme.

Medical management

Assessment

In addition to your usual physical and/or psychological assessment, screening for psychosocial risk factors that may delay or present a barrier to recovery, forms an important part of the assessment of a worker presenting with a work related injury or illness.

Using acceptable medical terminology assists an insurance agent to make better decisions about a worker’s compensation claim. If diagnosis is unclear, provide a provisional diagnosis.

Treatment

You may identify medical and treatment related services likely to contribute to the worker’s successful recovery. These may include specialist treatment or workplace rehabilitation services as described in the Payment and Services section of this guide.

Prior approval is required from the insurance agent before recommended treatment can commence. There are some specific exemptions to thisoutlined in the Payments and complaints section below.

Recommended treatment:

  • must be directly related to the work related injury or illness
  • should be discussed with the worker to establish clear, realistic expectations about what treatment is likely to achieve
  • should be included on the SIRA certificate of capacity so the insurance agent knows what services are required and what invoices to expect

The insurance agent will not pay for treatment that is:

  • experimental or not evidence-based
  • not ‘reasonably necessary’ to support the worker to recover and stay at work
  • not contributing to an objective improvement for the worker (particularly in relation to improving the worker’s capacity to work)
  • provided by a person who is not appropriately registered, qualified or authorised

Reviewing treatment effectiveness

Your role includes regularly reviewing the effectiveness of treatment with the worker and facilitating an evidence-based treatment approach. In particular this includes:

  • ensuring timely progression of treatment to an active, self-management approach
  • recommending cessation of treatment where there is no resulting objective improvement in function or work capacity within the expected timeframe

Reasonably necessary treatment

The insurance agent will only approve medical expenses that are reasonably necessary. This is treatment that is related to the work injury and should be:

  • effective in promoting recovery
  • appropriate for the injury and has the capacity to relieve the effects of the injury
  • the best option, compared to other forms of available treatment
  • generally accepted by the profession in achieving optimum recovery and return to work
  • cost effective

Certification

The SIRA certificate of capacity is the primary tool for you to communicate with all parties involved in the recover at work process. The certificate places emphasis on what the worker can do rather than what they cannot do.

A thoroughly completed certificate minimises the likelihood that an insurance agent will need to make contact with you to obtain additional information or clarification.

The certificate must include a clear diagnosis and treatment plan, as well as any factors that may have an impact on recovery. When stating the worker has capacity for work, you must complete the hours and days, as well as the ‘capacity’ section. If the worker has no capacity, you must provide an estimated timeframe in which you think the worker will have some capacity.

The certificate should not cover a period of more than 28 days, unless clinical reasoning supporting a longer timeframe is provided. For example, in the case of a serious injury or where there is surgery planned and recovery is known to be prolonged.

The insurance agent will use the certificate as one source of information when making decisions regarding the worker’s work capacity. Further information on completing the certificate is available on our website

Frequently asked questions about medical management

Q. If the claim has been accepted by the insurance agent, why has the treatment I have recommended been refused?

A. When an insurance agent reviews any request for treatment, they consider all medical evidence. If the medical evidence indicates the recommended treatment is not reasonably necessary, it may be refused. This evidence may be obtained from a number of sources, such as a treating specialist, independent allied health practitioner or an independent medical examiner.

If the worker wants to dispute this decision, they can contact their insurance agent, our Customer Service Centre, the Workers Independent Review Office (WIRO) or Workers Compensation Commission (WCC).

Q. Can a specialist act as a nominated treating doctor?

A. Yes, if the worker agrees and the specialist is willing to be available to communicate effectively with all parties, for example taking phone calls or participating in case conferences. If they cannot commit to being available for this, it is better for a local GP to be the nominated treating doctor.

Q. Can an insurance agent send a worker for an independent medical examination before receiving my medical report?

A. Not usually, but if information is not available within a reasonable period of time, the worker can be sent for an independent medical examination. More information on independent medical examiners is set out below.

Q. What should I do if I identify non-work related conditions, risk factors or barriers?

A. If you identify barriers to recovery that are not directly related or attributable to the work related injury or illness (e.g. a pre existing psychological condition) ensure the worker receives the necessary treatment and/or medication using the appropriate mechanisms e.g. Medicare or private health fund. You should discuss the impact of the interaction between work and non work related factors with the worker.

If you feel it is appropriate to talk to the insurance agent about any non work related issue, you should seek consent from the worker to do so. It may not be necessary to disclose all details but rather flag the existence of a barrier and advise that management will occur concurrently with the work related injury or illness.

Recover at work

You can contribute to a worker’s successful recovery at work in a number of ways.

Talk to the employer

Ask the employer about their plan to support the recover at work process. This can include:

  • the nature of suitable work options
  • hours of available work
  • equipment or changes to the working environment

Talk to the worker about their job

Ask the worker about:

  • their work tasks and associated work demands
  • the work environment (physical environment and support mechanisms)
  • what they think they could do at work while recovering from their injury
  • what activities they are doing at home
  • any support they think they may require to recover at work

Correcting misconceptions and discussing the health benefits of work

Workers have their own beliefs and expectations about health and work. These don’t always align with available evidence and may be unhelpful for their long term health.

There is evidence that the long term consequences of time off work may be greater than the consequences of the original health problem.5 This provides a platform to discuss the health benefits of work. As the worker is likely to be receptive to your opinion, simple messages delivered in a clinical environment can assist workers to develop an evidence-based view of the relationship between health and work.

The table below describes common misconceptions and provides supporting evidence to the contrary, with some messages to assist in your discussions with the worker about the health benefits of work.

Worker misconceptions

Evidence based response6

My injury or illness will be made worse by work

  • safe work is good for you - physically, psychologically, socially and financially
  • pain or discomfort does not always mean your injury or illness is getting worse
  • recovering at work, as with any increase in activity, may be uncomfortable or difficult for a time but does not usually cause any lasting negative effect
  • incremental, time-based increases in function (despite symptoms) are likely to achieve better long term outcomes

My injury or illness is the result of underlying damage or disease

  • there is often little or no underlying disease or permanent damage, and even if there is, incapacity is not inevitable
  • clinical symptoms do not reliably correlate with findings on investigative imaging

My injury or illness will be cured by medical intervention and treatment alone

  • treatment is beneficial when it is tailored to your work tasks
  • clinical management is often about managing symptoms to allow you to continue or resume your usual activities at home and at work

My injury or illness will improve or be cured with rest, eg I cannot return to work until I am completely better

  • staying active (including safe work) promotes recovery
  • for most people with a workplace injury, time off work is not medically necessary
  • common health problems can often be accommodated at work with the necessary adjustments and support
  • the longer a worker is off work, the less likely they are to ever return7

I will lose my job if I have a work related injury and/or claim

  • employers must not dismiss a worker because of a work related injury within six months* from when they first become unfit as a result of the injury*
  • however, the worker must make reasonable efforts to return to suitable employment with their pre-injury employer and, if this is not possible, with a different employer (see information on our vocational rehabilitation programs for a worker who cannot return to their pre-injury employment below)**

Providing recommendations about work

On the certificate of capacity you must provide a recommendation about the worker’s capacity for work. You should consider the following when formulating your recommendation.

Determine what the worker can do

Our certificate of capacity asks you to provide an opinion about what the worker can do in relation to specific tasks such as lifting, carrying, pushing, pulling, driving, standing or other considerations (e.g. psychological or cognitive) as relevant. You should focus on what the worker can do as opposed to what they cannot do. It may be helpful to ask the worker what activities they are performing at home that could transfer readily to their work environment.

A worker may not be able to return to their usual work or usual hours immediately after their injury. Their employer is obliged to support the worker to recover at work. The information provided on the certificate of capacity can help the employer to find suitable work options that may include:

  • parts of the worker’s usual job
  • the same job with reduced hours
  • different tasks altogether
  • work at a different site
  • training opportunities
  • a combination of some or all of the above

Other forms of support, including provision of equipment, workplace modifications or changes in work practices to reduce work demands, may also be necessary to assist a worker to recover at work. You should note any support recommendations on the certificate of capacity.

Support the worker to recover at work

Given the health risks associated with long periods out of work, advice to stay off work should be viewed as a significant clinical intervention with potentially serious long term consequences.8 Accordingly, when assessing the worker’s capacity consider if time off work is medically necessary or whether the worker could recover at work in some capacity with the right support.

If you feel further assessment may be helpful to inform your recommendations about work capacity, you may request a workplace or functional assessment. This involves the worker performing actual or simulated work tasks which are assessed by an approved workplace rehabilitation provider.


Communicating with the worker's support team

In the workers compensation system, returning to work and recovering at work, is a managed process involving a multidisciplinary team. Success depends on the integration of sound clinical, workplace and insurance claims management and agreement about the workers progress.

Each member of the team has an important role to play in supporting a worker to return to, and where possible, to recover at work.

Clear communication and collaboration with others in the support team is essential to:

  • understanding the worker’s capacity, needs and strengths
  • identifying any barriers or risks to recovery and effective strategies to address these issues
  • developing shared goals and recovery expectations
  • ensuring the worker receives consistent messages from team members
  • ensuring the right services are provided at the right time

This diagram illustrates the communication responsibilities of all parties involved in supporting an injured worker

The worker

The worker’s primary role is to focus on returning to and recovering at work, in some capacity, as soon as possible. The worker’s responsibility is to ensure they receive the assistance they require, to remain focussed and achieve their goals. These include:

  • notifying their employer of their injury or illness as soon as possible
  • consulting a doctor and obtaining a SIRA NSW certificate of capacity and providing a copy to their employer and insurance agent
  • attending reviews with their doctor and maintaining a current certificate of capacity
  • actively participating in their treatment
  • actively participating in their recover at work planning
  • making reasonable efforts to return to their usual work or suitable work as soon as possible when they have capacity to do so
  • attending appointments and assessments arranged by the insurance agent case manager

The employer

The employer is obliged to provide suitable work to support recovery at work.* The greater the employer’s ability to accommodate a worker while they recover, the less likely the worker will need time away from the workplace as a result of their injury. According to the legislation, this should be as far as possible, the same or equivalent work that was performed before the injury.**

The employer uses the recommendations you provide on the certificate of capacity to identify suitable work options in collaboration with the worker. The more information you provide, the easier it is for the employer to identify tasks that align with the worker’s current capacity for work. You may find it helpful to contact the employer to discuss the worker’s needs or the employer may contact you.

The employer can assist you by:

  • providing information about the workplace, the worker’s usual job and available short term suitable work options
  • discussing any risks or barriers that may have an impact on the worker’s recovery
  • developing a recover at work plan to ensure the worker’s recovery progresses as expected and they receive the support they need in the workplace

Larger employers may have a return to work coordinator to assist them with their responsibilities. You may be dealing directly with the employer or their return to work coordinator.

* Section 49 of the Workplace Injury Management and Workers Compensation Act 1998

** Section 49(2) of the Workplace Injury Management and Workers Compensation Act 1998

The insurance agent case manager

The insurance agent case manager coordinates all aspects of a worker’s claim and is the primary contact for the worker and others involved in assisting the worker to return to and recover at work. The insurance agent case manager:

  • makes early contact with the worker, employer and you after receiving notification of a claim to determine the assistance the worker requires
  • authorises and arranges payment for ‘reasonably necessary’ medical and related expenses (see page 6 for a definition of reasonably necessary)
  • determines a worker’s entitlement to weekly compensation payments and commences payments
  • assists the employer to meet their obligations to support the worker to recover at work
  • may arrange assessments or services to help determine a worker’s capacity for work or identify suitable employment

The information you provide on the SIRA certificate of capacity allows the insurance agent to promptly organise necessary support and services for the worker. You can contact the insurance agent at any stage to discuss specific needs, barriers or issues that may have an impact on the worker’s recovery at work or return to work.

Other health practitioners

Other treatment practitioners may be involved in the management of the workers injury/condition and may assist you to facilitate a worker’s recovery by:

  • conducting a detailed assessment of the worker and providing information to inform and/or confirm diagnosis and the treatment strategy
  • providing treatment to improve the worker’s capacity for work
  • providing information about the worker’s progress to inform recommendations about capacity for work
  • educating all parties about the health benefits of work

The approved workplace rehabilitation provider

We approve workplace rehabilitation providers to deliver specialised services to assist employers to meet their return to work obligations and assist workers to return to and recover at work. The approved workplace rehabilitation provider assists you by:

  • conducting a workplace or functional assessment to provide detailed information about the worker’s capacity for work, their pre-injury work and available suitable work options
  • providing advice about reducing work demands through changes to a work environment or work practices
  • collaborating with other members of the support team to identify and develop strategies to address barriers to recovery and develop a tailored recover at work plan; our recover at work planning tool will assist you
  • educating the worker and employer about their obligations and/or the health benefits of work
  • conducting a vocational assessment to identify suitable employment options with a new employer (where appropriate)
  • preparing and/or assisting the worker to obtain suitable employment with a new employer (where appropriate)

Referral to an approved workplace rehabilitation provider

You may consider recommending a referral on the certificate of capacity where:

  • significant psychosocial barriers have an impact on recovery at work
  • a worker’s injury is complex and/or recovery may be difficult or lengthy
  • recovery is not progressing as expected
  • there are communication issues, relationship breakdowns or conflict in the workplace
  • suitable employment has not been offered and/or is not available
  • additional information about the worker’s capacity for work, work options or work environment is required

The insurance agent will discuss the referral with the worker, and engage an approved workplace rehabilitation provider.

Other medical practitioners

Injury management consultant

An injury management consultant is a registered medical practitioner experienced in occupational injury and workplace rehabilitation. The injury management consultant acts as a facilitator to assist you, the employer, the insurance agent and the worker, to negotiate more complex cases where there are barriers delaying a worker’s recovery at or return to work.

They may assist by:

  • liaising with you about the worker’s readiness for work, timeframes, and management options
  • contacting the employer and/or visiting the workplace to assist in identifying suitable work options
  • providing recommendations for gradually upgrading the worker’s capacity for work
  • providing advice about the workers compensation system, the claims process and potential impact of delayed recovery at work

The insurance agent may initiate the involvement of an injury management consultant or you can request this support by contacting the insurance agent. You will need to talk to the injury management consultant in your role as the nominated treating doctor. The agreed outcomes from this process will be given to you, the worker and the employer, for further action.

The independent medical examiner

The independent medical examiner is a registered medical practitioner who provides an impartial medical assessment when requested by the worker, their legal representative or the insurance agent. A referral for an independent medical examination occurs when medical information is unavailable, inadequate, inconsistent and/or where these issues are not able to be resolved by other means.

The independent medical examiner may provide advice about accepting a claim, ongoing liability, the worker’s capacity for employment and/or ongoing treatment. They may also recommend additional or alternative treatments if they believe it is in the interest of the worker. The independent medical examiner report goes to the person who requested the assessment.

See our page on medical practitioners for further information.

Methods of communicating with the support team

Regular communication with the support team will help facilitate a positive outcome for the worker. You may wish to make your preferences about communication known to the team eg preferred times and how you would like to be contacted. The table below outlines the key communication tools that you will encounter in your role as the nominated treating doctor.

Tool

How to use

Owner

SIRA certificate of capacity

Primary communication tool for the nominated treating doctor to provide complete and accurate information to ensure everyone involved has a clear understanding of the worker’s needs. The certificate is available on our website. For hard copies call us on 1300 799 003.

  • Part A can be completed by the worker or doctor
  • Part B to be completed by the doctor
  • Part C is a declaration that the worker completes
  • our website has detailed information about completing the certificate

Nominated treating doctor

Injury management plan

Outlines the agreed support and plan for the worker in terms of treatment, rehabilitation and recovery at work.

  • the insurance agent case manager, in consultation with the worker and others, completes this plan in the first four weeks post injury.
  • the insurance agent will include in the plan information on the SIRA certificate of capacity, and may contact the nominated treating doctor if clarification is required.
  • you may receive copies of the plan and any updated plans throughout the recovery process.

Insurance agent case manager

Recover at work plan

Outlines the suitable work offered by the employer, other agreed workplace support, and stages or steps proposed to gradually progress the worker towards their usual work. A recover at work planning tool is available on our website.

  • developed by the employer and potentially an approved workplace rehabilitation provider in consultation with the worker
  • input or endorsement may be required from the doctor to ensure the plan meets the worker’s needs, and aligns with anticipated timeframes for recovery
  • the worker may also bring a copy of the plan to their appointment with their doctor to discuss progress and goals

Employer and approved workplace rehabilitation provider (if involved)

Case conference

Is a face to face meeting, video conference or teleconference with any or all of the support team for the purpose of recover at work planning.

  • a  case conference can be held at any time
  • it should be booked in advance at a mutually convenient time
  • the person initiating the case conference should provide an agenda with key points to be discussed
  • all parties involved should contribute openly and honestly when addressing the issues that led to the case conference being arranged
  • you must document the discussion, including those spoken to, key points discussed, agreed outcomes, and duration (for invoicing purposes) in the worker’s case notes
  • case conferences may be billed in addition to the consultation using the appropriate payment classification code, see the Workers Compensation (Medical Practitioner Fees) Order for details, noting that treatment planning discussions between the nominated treating doctor and other treating practitioners are considered a normal interaction and are not chargeable

All members of the support team

Report and/or information requests

Can be requested by the insurance agent case manager, legal provider, approved workplace rehabilitation provider or injury management consultant.

  • requests from a worker’s legal representative for information that you have already provided to the insurance agent should be redirected to the insurance agent case manager
  • information should be provided as soon as possible and within 10 working days to reduce delays for the worker
  • if you are unable to provide the information within a reasonable timeframe, you should advise the requesting party as it may be possible to negotiate an extension, or they may choose to withdraw the request
  • invoicing for reports that do not relate to the routine management of a worker’s injury, and are not required as part of a dispute or potential dispute, can be done as per the current fees order. If the report is requested as part of a current or potential dispute then the Workplace Injury Management and Workers Compensation (Medical Examinations and Reports) Order applies.
  • prepayment in whole or part cannot be made for reports

Insurance agent case manager, legal provider, approved workplace rehabilitation provider or injury management consultant


Essential information for medical practitioners

Confidentiality of information

Medical practitioners should provide information relevant to the worker’s injury or illness to other relevant parties as part of the workers compensation process. The worker provides consent on the certificate of capacity for you to communicate with parties involved in the management of their injury and claim. This generally includes the employer, other treating practitioners, insurance agent and workplace rehabilitation provider. It can also include an injury management consultant or the Workers Compensation Commission (or an approved medical specialist).

If you receive a request for information and are concerned about the right of that party to obtain confidential information about the worker, you should establish that the request has been made with the worker’s consent. A copy of a signed and dated consent to disclose relevant confidential information to the party concerned is considered sufficient for the release of information.*

Medical notes requested by the insurance agent

You may provide medical notes relevant to the injury, however you are not obliged to, unless requested under direction (from the Workers Compensation Commission), subpoena or other legal process that remains unchallenged.

It would not usually be necessary for an insurance agent to request an entire medical record, unless the record relates solely to the injury giving rise to the claim.

Where a worker is claiming a psychological injury or injury in the nature of a disease contracted by a gradual process, more extensive records may be required than would be necessary for a single event injury.

If you provide medical notes to the insurance agent, you can redact information that is not related to the workers compensation claim.

Excessive requests for information by the insurance agent

We suggest insurance agents pose specific questions to the medical practitioner allowing provision of information that is succinct and relevant to the purpose of the request.

If you receive requests from the insurance agent for information you have already provided, remind the insurer when the information was provided and confirm that it can be located on file.

Similarly, if you receive a request for what you believe to be an excessive amount of information, contact the insurance agent  to discuss the issue.

If you are unsure about the information request or if you want advice on handling excessive requests for information contact our Doctors Helpline on 1800 661 111.

Frequently asked questions about privacy

Q. As a specialist, what information am I required to include in the initial consultation report to the insurance agent?

A. As per the Workers Compensation (Medical Practitioner Fees) Order the report will contain:

  • the patient’s diagnosis and present condition
  • the patient’s likely capacity for pre-injury work or suitable employment
  • the need for treatment or additional rehabilitation
  • medical co morbidities that are likely to impact on the management of the worker’s condition (in accordance with privacy considerations)
Q. What other doctors are involved in the worker’s claim, and am I as the nominated treating doctor required to communicate with them when requested?

A. An insurance agent may refer a worker to an injury management consultant when there are barriers to a workers recovery at or return to work. When you agree to be the nominated treating doctor to a worker, you are obliged to communicate with all relevant parties involved in their return to work.

Q. Can an employer insist on accompanying a worker when they visit me?

A. No, an employer cannot insist that they or their representative is present during a consultation. However, if an employer (or their representative) accompanies the worker to the consultation, you can invite them in at the conclusion, to update them and work together in recover at work planning. The employer’s representative can be invited to attend a case conference provided the worker consents.

Q. Can I edit sensitive medical information not related to the worker’s injury from the report for the insurance agent?

A. Yes, you can redact information that is not related to the workers compensation claim.

Payments and services for workers

The insurance agent is responsible for approval and payment of these services.

Medical and treatment services

There are a range of medical and treatment services you may recommend.
These may include:

  • medical treatment, ambulance services and hospital treatment
  • allied health treatment
  • workplace rehabilitation

The insurance agent is responsible for coordinating and paying for services that are reasonably necessary.

Weekly payments

If a worker is unable to return to their usual work or work hours, they may be eligible to receive weekly compensation payments.

For most workers, this weekly payment is based on a percentage of their pre-injury average weekly earnings. After 13 weeks, a worker’s weekly payment amount may reduce depending on the worker’s capacity for work and how many hours they are actually working.

Entitlement to long term weekly payment support (after a maximum of 130 weeks) is only available if certain requirements are met.

Our vocational rehabilitation programs

We funds programs to help workers who need additional assistance to recover at work. The insurance agent or SIRA approves these programs which can include:

  • work experience and/or work trial with a host employer
  • equipment and workplace modifications
  • retraining to assist workers to develop new skills and qualifications to keep their job or get a new job
  • funds to address an immediate barrier preventing a worker accepting an offer of suitable employment with a new employer e.g. access to transport, suitable clothing
  • incentives to encourage employers to employ workers with a work related injury or illness

Extensive information can be found on our website about all our programs under help with getting people back to work.

Information on program payments and services for workers is included in our Injured at work guide on our website.

Payments for medical practitioners

Fees for medical practitioners are based on the AMA list of medical services and fees. Other SIRA specific fees have been agreed with the relevant medical association. The fee levels reflect the expectation that you will support recovery at work or return to work and provide optimal services in this pursuit.

Fee schedules

The fee schedules for medical practitioners, reference the AMA List of Medical Services and Fees from 1 January each year. Each year SIRA NSW publishes a fee schedule in the NSW Government Gazette in line with the latest AMA rates.

Gazetted fees are the fees set in the schedule and the maximum amount that can be paid for a service. This amount is legally binding and cannot be billed at higher rates.

For payment of medical consultations and services, the AMA item codes must be used. Additionally, there are SIRA specific services that are not found in the AMA List and are relevant for nominated treating doctors. These are available on our website.

Invoicing

We require you to provide itemised invoices before payment can be made by the insurance agent. To ensure invoices are processed without delay, please include the following:

  • the worker’s first and last names and compensation claim number
  • payee details
  • ABN of the payee
  • the name of nominated treating doctor who provided the service
  • date the service was provided
  • AMA item number and/or SIRA payment classification code
  • Medicare provider number
  • service cost for each AMA item number or SIRA NSW classification code
  • service duration (if applicable)

Payment complaints

Payments by insurance agents are to be made within a reasonable timeframe upon receipt of a correctly completed invoice where liability has been accepted.

Step 1: If you have a complaint about the payment of your account, contact the insurance agent case manager responsible for payment. If you are unable to resolve the issue with the case manager, you should escalate the matter to the case manager’s supervisor or the insurance agent’s complaints department.

Step 2: If after completing step 1 you have not been able to resolve the matter, you should contact our Customer Service Centre on 13 10 50, or our Doctors Helpline on 1800 661 111. We will ask you to provide evidence of your attempts to address the problem with the insurance agent.

SERVICE
EXEMPTION

Any reasonably necessary service

Provided within the first 48 hours post injury.

Consultations with nominated treating doctor

Any consultation with the nominated treating doctor in relation to the injury claimed, except for consultations for mental health treatment items AA905 and AA910 in the Australian Medical Association List of Medical Services and Fees.

Specialist medical practitioner consultations

First consultation for the injury with the first specialist medical practitioner on referral by the worker’s nominated treating doctor, and treatment provided within the initial consultation. Subsequent consultations require approval from the insurance agent, who has 21 days to respond after receipt of your request.

Pharmacy

Pharmacy items prescribed by the nominated treating doctor or specialist medical practitioner for the injury in the first three weeks post injury to a maximum of $500, or items excluded from the Pharmaceutical Benefits Scheme to a maximum of $100.

X-ray

Plain x-rays performed on referral from the nominated treating doctor or specialist medical practitioner in relation to the injury claimed and provided within one week of injury.

Public hospital

Any services provided in public hospitals that are provided by or consequent upon presentation at the hospital’s emergency department for the injury claimed within one month of the date of injury.

Hearing needs assessment

The initial hearing needs assessment only. The hearing service provider must be approved by the Office of Hearing Services. The nominated treating doctor must have referred the worker to a specialist ENT physician to determine that the hearing loss is work related and that there is binaural hearing loss of 6 percent or more.

Frequently asked questions about payments and invoicing

Q. Is a nominated treating doctor entitled to charge for completion of each SIRA certificate of capacity?

A. No, only the initial certificate is chargeable. If a different treating doctor has already issued a certificate, no further certificates can be paid for.

Q. Can cancellation or non attendance fees be charged?

A. No. Our fees orders do not permit cancellation fees by a treating medical practitioner.

Q. Can I ask a worker to pay for their consultation?

A. We do not support doctors billing a patient privately and directing the worker to recover the costs from their insurance agent and/or employer, as this may place undue financial stress on the worker. The best outcome for the worker is for the doctor to invoice the insurance agent directly.

If however the claim is disputed, the doctor should confirm with the insurance agent first, that the worker has received payment of weekly benefits. If the worker is receiving payment at the time of consultation, the doctor should also be paid by the insurance agent during this period. If no payments have been made to the worker, you may invoice Medicare for the consultation. If you have any questions regarding payment, speak to the insurance agent or contact our Doctors Helpline on 1800 661 111.

Q. When is it appropriate to invoice using a Level C consultation?

A. SIRA's schedules for medical services are based on complexity, rather than time spent. You must be able to justify invoicing a Level C consultation if requested by the insurance agent. Good case notes will assist with this. Services invoiced above Level B consultations should include consideration of the following to enable assessment of the complexity of the consultation:

  • nature of the condition
  • time since the work related injury or illness was sustained
  • changes in treatment, management, work restrictions and/or capacity for work during the consultation
  • frequency of consultations with the nominated treating doctor
Q. Are different rates payable for consultations on Saturdays and Sundays?

A. If the practice normally operates on Saturday or Sunday, the consultation is within normal hours. You can claim out-of-hours rates only in an emergency where the consultation is conducted outside the advertised hours of the clinic and where urgent medical treatment is provided. Justification will be required for charging out of hours rates.

Q. Can I charge for reading and writing letters, reports and plans and participating in case conferences?

A. A communication fee can be charged for a reasonable amount of time spent in the management of an injury, when over and above that required in normal clinical practice for a non-workers compensation patient, whether verbal, in writing or face to face. Payment classification code WCO002 should be used for this purpose.

Q. Can I charge for faxing?

A. Sending a fax is not chargeable. The time taken to prepare the information to be faxed can be charged using code WCO002.

Q. Can I charge for communicating with other treatment practitioners about the worker’s treatment?

A. In most cases, communication regarding treatment is considered a usual interaction between a nominated treating doctor and other practitioners and cannot be charged as a case conference item. However, if the communication is regarding return to work issues, or the communication extends beyond that which would be required for a non-workers compensation patient, then it is chargeable.

Q. Can I charge for the time it takes to edit or redact information that does not relate to the worker’s injury?

A. Yes. You can charge for the time spent to edit a file using code WCO002.

Q. What do I do if the worker’s claim is disputed?

A. Regardless of the status of the claim, if the worker has a genuine medical condition, it is important they receive the treatment required. If a claim is disputed, treatment can be provided through the Medicare system. If the claim is accepted at a later date, Medicare will recover the costs from the insurance agent.

Q. Who pays the nominated treating doctor if a claim is disputed and there are outstanding fees payable?

A. If the claim is disputed the insurance agent should pay all fees up to the date the claim is disputed. It is usual practice for the insurance agent to let you know that the claim has been disputed. If you have not been informed you should submit any outstanding invoices as soon as possible to the insurance agent. The worker is ultimately responsible for paying for treatment if a claim is not accepted or for treatment provided after a claim is disputed.

Q. How do I bill for a service that is not on the AMA List of Medical Services and Fees?

A. You cannot bill for medical services that are not listed in the AMA List of Medical Services and Fees or the SIRA Fees Orders.

Q. How much time should I allocate for a case conference?

A. The worker may have their usual consultation with you before or after the case conference. You may need to allow time for two appointments: one for the case conference and the other for the consultation. The person requesting the case conference should provide an agenda with key points to be discussed, giving you some idea of how long the conference will take. Keep a record of the duration for invoicing purposes (note: payment classification code WCO002 should be used for invoicing of case conferences).


Further assistance

SIRA Doctors Helpline: Call our Doctors Helpline for specific advice about claims on 1800 661 111 or email, doctorinformation@sira.nsw.gov.au

SIRA Customer Service Centre: For general information about work health and safety and workers compensation call our Customer Service Centre on 13 10 50  or search our website www.sira.nsw.gov.au

Workers Independent Review Office (WIRO) on 13 94 76 or via their website, www.wiro.nsw.gov.au

The Australian consensus statement on the health benefits of work is a commitment statement created by the Australasian Faculty of Occupational and Environmental Medicine and the Royal Australasian College of Physicians.

Talking about a return to work - conversation starters [for doctors] is a useful guide created by the Australasian Faculty of Occupational and Environmental Medicine and the Royal Australian College of General Practitioners for use by general practitioners.

Realising the health benefits of work is a comprehensive document published by the Australasian Faculty of Occupational and Environmental Medicine and The Royal Australasian College of Physicians.


References

  1. Cheng and Hung. Randomized Controlled Trial of Workplace- based Rehabilitation for Work-related Rotator Cuff Disorder. J Occup Rehab (2007) 17:487-503.
  2. Waddell G, Burton AK. Is work good for your health and wellbeing? The Stationery Office. 2006.
  3. Australian Consensus Statement on the Health Benefits of Work. A Position Statement. Australasian Faculty of Occupational and Environmental Medicine and The Royal Australasian College of Physicians. 2011.
  4. Johnson D, Fry T. Factors Affecting Return to Work after Injury: A study for the Victorian SIRA Authority. Melbourne: Melbourne Institute of Applied Economic and Social Research; 2002.
  5. Waddell G, Burton AK. Is work good for your health and wellbeing? The Stationery Office. 2006.
  6. Waddell G, Burton AK. Is work good for your health and wellbeing? The Stationery Office. 2006.
  7. Johnson D, Fry T. Factors Affecting Return to Work after Injury: A study for the Victorian SIRA Authority. Melbourne: Melbourne Institute of Applied Economic and Social Research; 2002.
  8. Waddell G, Burton AK. Is work good for your health and wellbeing? The Stationery Office. 2006.