Consultation Draft Guidelines for the Provision of Relevant Services (Health and Related Services)

Part 1: About the Guidelines

Legislative framework for the Guidelines

Guideline-making powers

1. The Guidelines for the Provision of Relevant Services (Health and Related Services) (the Guidelines) are made under section 26E of the State Insurance and Care Governance Act 2015 (the Act), which provides that the State Insurance Regulatory Authority (SIRA) may issue guidelines concerning the provision of relevant services by relevant service providers (RSPs).

2. RSPs are required to comply with all relevant parts of the Guidelines.

Interpretation

3. The Guidelines are to be read in conjunction with the relevant provisions of the:

(a) Act and the State Insurance and Care Governance Regulation 2021 (the Regulation) and in a manner that supports the principal objectives of SIRA as set out in section 23 of the Act.

(b) Motor Accident Injuries Act 2017, Workers Compensation Act 1987, the Workplace Injury Management and Workers Compensation Act 1998, and the Regulations and guidelines made under those Acts.

4. The Guidelines prevail to the extent of an inconsistency between the guidelines made under the workers compensation and motor accidents legislation (as per s26E(5) of the Act).

Commencement

5. The Guidelines will take effect and apply to all relevant services from [insert date].

6. The Guidelines will apply until SIRA amends, revokes, or replaces them in whole or in part.

Application and purpose of the Guidelines

7. The Guidelines apply to the provision of relevant services as defined in Clause 4A(1) of the Regulation by RSPs (see Appendix A ).

8. The purpose of the Guidelines is to specify SIRA’s service and billing expectations for the provision of relevant services by RSPs in the workers compensation (WC) and compulsory third party (CTP) schemes.

9. RSPs are required to comply with the parts of the Guidelines that are relevant to them. To avoid doubt, Part 3 of the Guidelines applies to RSPs providing the relevant services prescribed in Clause 4A (1)(a) to (n), (p) to (w), (y), (za) and (zc) of the Regulation– see Appendix A.

10. Clause 4C(2)(b) of the Regulation makes non-compliance with the Guidelines a circumstance in which SIRA can issue a direction.

Definitions

11.  Allied health services: relevant services prescribed in Clause 4A (1) (a), (c), (d), (e), (g), (i), (l), (m), (n), (p), (q) (r) (s), (u), and (v) of the Regulation – see Appendix A.

12. Direction: a direction given under section 26D of the Act – see Appendix B

13. Insurance, compensation or health authorities, government agencies or statutory bodies: includes, but is not limited, to bodies such as other Australian jurisdictions’ workers compensation and/or motor accidents schemes/authorities; NSW Health, the Commonwealth Department of Health, and other Australian jurisdictions’ health departments; the Health Care Complaints Commission; a national health practitioner registration board, or a registration board operating in an Australian jurisdiction; the Commonwealth Professional Services Review; the National Disability Insurance Authority; and the NDIS Quality and Safeguards Commission.

14. Medico-legal services: relevant services prescribed in Clause 4A (1)(za)(i)(ii) and (iii) of the Regulation – see Appendix A.

15. Overservicing - a pattern of service provision that varies significantly from the provider’s peers (ie practitioners of the same profession), taking into account factors such as the complexity/severity of injuries being treated.

16. Relevant services: services prescribed in Clause 4A of the Regulation– see Appendix A

17. Relevant service provider (RSP): a provider of relevant services (see above)

18. Support team: A multidisciplinary team that can include the employer, insurer case manager, doctor, allied health practitioner, rehabilitation provider and other RSPs.

Part 2. Code of conduct for RSPs delivering relevant services

19. All relevant services are to be delivered by RSPs in compliance with the following code of conduct:

(a) Be professional, honest and impartial

(b) Treat people with empathy and respect

(c) Not engage in overservicing or engage in behaviour that leads to overbilling or delivering more services than necessary

(d) Not provide or bill for relevant services in a misleading or deceptive way intended to result in financial or personal gain

(e) Manage conflicts of interest to ensure services provided best meet the needs of injured persons

(f) Always respect the confidentiality of injured persons’ personal and health information.

Part 3: Requirements for the provision of relevant services

Registration/accreditation requirements

20. To provide relevant services, the RSP must (where required) be registered or otherwise accredited to practice and deliver the services they are providing.

21. Relevant services cannot be provided by a RSP who has:

(a) had their registration or licence under any relevant law, their accreditation or registration by, or membership of, a self-regulating professional organisation, limited or subject to any condition as a result of a disciplinary process or been suspended or disqualified from practice ^[1]

(b) had a complaint upheld about them or action taken by insurance, compensation or health authorities, government agencies or statutory bodies regarding their conduct

• (i) in any role in any insurance or compensation system in any Australian jurisdiction or
• (ii) in the provision of health services.

(c) been convicted of any criminal offence or have any pending criminal charges, or any civil proceedings lodged against them or their practice.

22. Students being supervised by a RSP must not provide relevant services.

Notification requirements

23.  In providing relevant services, the RSP must notify SIRA (in writing within seven calendar days) if they become aware that:

(a) there are changes to their registration, licence, accreditation, or membership of a self-regulating professional organisation

(b) there are any disciplinary proceedings against them with their relevant registration body, accrediting body, or self-regulating professional organisation

(c) they have been referred to, or is under investigation by, a relevant clinical, professional, or accreditation body or self-regulating professional organisation

(d) a complaint has been made about them to (and/or is under investigation by) an insurance, compensation or health authority government agency or statutory body regarding their conduct in any role in any insurance or compensation system in any Australian jurisdiction or in the provision of health services

(e) information provided to SIRA in any application (if relevant) was incorrect or incomplete.

Communication requirements

24. RSPs must respond to SIRA communication in the form, timeframes and manner required and requested by SIRA from time to time.

25. If requested by SIRA, RSPs must provide an email address that to which can be used for all written communication.

Part 4: Requirements for the delivery of relevant services

26. Relevant services must be delivered in accordance with:

(a) the current version of the nationally endorsed Clinical Framework for the Delivery of Health Services ^[2]. In particular, note its five principles:

• (i) measure and demonstrate the effectiveness of treatment
• (ii) adopt a biopsychosocial approach
• (iii) empower the injured person to manage their injury
• (iv) implement goals focused on optimising function, participation and return to work
• (v)  base treatment on best available research evidence.

(b) the current version of the Australasian Faculty of Occupational and Environmental Medicine’s Australian and New Zealand Consensus Statement on the Health Benefits of Work as current from time to time, including:

• (i) discussing the health benefits of good work, if the injured person is employed
• (ii) encouraging and supporting an injured person to stay at work in some capacity, or recover at work
• (iii) discussing recovery through work options with the injured person, employer, and support team
• (iv) encouraging an injured person to stay active in their usual activities, as appropriate.

(c) value-based healthcare and the quadruple aim, which strives to deliver care that improves:

• (i) health outcomes that matter to people
• (ii) experiences of receiving care
• (iii) experiences of providing care
• (iv) effectiveness and efficiency of care.

27. RSPs must complete any additional training at the request of SIRA, to the standard required by SIRA, within the required timeframe and at the practitioner’s own expense.

28. RSPs must fully cooperate with reviews by injury management consultants, or any other independent review of relevant services arranged by insurers, in the form, timeframes and manner required by SIRA from time to time.

Part 5: Requirements for prescription of medication

32. Medications must be prescribed through the Pharmaceutical Benefits Scheme (PBS) unless there are extenuating circumstances, such as ^[5]:

(a) a medication is not available on the PBS, and after the first month from the date of injury pre-approval has been obtained from the insurer to prescribe it privately

(b) a medication is available on the PBS, but the patient does not meet the criteria for PBS prescribing

(c) the quantity of medication or number of repeats being prescribed for a medication available through the PBS falls outside the PBS prescribing criteria, can be clinically justified by the prescribing practitioner, and after the first month from the date of injury pre-approval has been obtained from the insurer.

33. Private prescription of any high-risk medication (i.e. opioids, medication-assisted treatment of opioid dependency, injectable narcotics, benzodiazepines, Z-drugs, or medicinal cannabis) and drugs of addiction (Schedule 8 ^[6]) that is not available through the PBS, or that is available through the PBS through a private prescription, must be accompanied by a written clinical rationale provided to the insurer.

Part 6: Requirements for provision of relevant medico-legal services^[7]

34. In the provision of relevant services that are medico-legal services, RSPs who are medico-legal providers must:

(a) act without bias and in a way that does not give rise to an apprehension of bias in the performance of their responsibilities

(b) comply with the Procedural Direction PIC4 – Expert Witness Evidence and any subsequent procedural directions issued by the President of the Personal Injury Commission relating to expert witness evidence, and promptly notify SIRA of any compliance breaches

(c) have access to the necessary resources and infrastructure to do all administrative activities necessary for the role

(d) comply with all legal requirements for practice, including relevant policies and codes of conduct

(e) comply with the standards and conduct for medico-legal consultations, examinations and reports, as set out in the Medical Council of NSW’s Guideline for Medico-Legal Consultations and Examinations in effect at the time of the relevant service. This applies to all RSPs undertaking medico-legal work in the CTP and WC schemes. Where the Guideline for Medico-Legal Consultations and Examinations refers to the Medical Board of Australia’s Good Medical Practice: A Code of Conduct for Doctors in Australia, this only applies to RSPs who are medical practitioners under the Health Practitioner Regulation National Law (NSW).

(f) not provide treatment advice and/or services to injured persons referred to the RSP for examination or assessment in their capacity as a medico-legal practitioner

(g) not accept a referral or examine an injured person if the RSP has a conflict of interest (personal, work-related, or financial)

(h) not engage in activities or publicly express opinions that might be perceived to compromise the practitioner’s ability to undertake the medico-legal role in an impartial and unbiased manner

(i) not undertake medico-legal assessments outside of their area(s) of expertise.

Part 7: Requirements for RSPs providing allied health services

35. In the provision of allied health services RSPs must:

(a) inform the nominated treating doctor (WC)/treating doctor (CTP) (if the referral was not received from that doctor) that they are treating the injured person

(b) when an injured person is being transitioned from one allied health practitioner to another for management of the same injury area:

• (i) provide concurrently no more than two sessions per practitioner to facilitate transition of management (except in cases of severe injury)
• (ii) collaborate to ensure effective continuation of the injured person’s rehabilitation.

(c) not exceed a maximum class size of six participants in group classes provided by physiotherapists, exercise physiologists, chiropractors, osteopaths, psychologists, and counsellors (workers compensation scheme only).

Requirements for use of Allied Health Treatment Request forms^[8]

36. In the provision of relevant services, RSPs who are allied health practitioners must:

(a) submit an Allied Health Treatment Request (AHTR) form (using the form approved by SIRA – available on SIRA’s website) for approval of treatment proposed, except where treatment is:

• (i) pre-approved in the workers compensation scheme – see Part 4 of the Workers Compensation Guidelines
• (ii) for injured persons with severe injury (where use of the AHTR is optional).

(b) not seek approval for more than 8 treatment sessions per AHTR

(c) must tailor all requests for treatment via an AHTR to the injured person’s individual clinical presentation with respect to both the number and type of treatment consultations

(d) make evidence-based treatment requests and specify how outcomes that empower injured persons to manage their injury and maximise their independence will be measured and demonstrated in the AHTR.

Part 8: Requirements for use of prostheses

37. Surgical prostheses must be selected from the Department of Health Prostheses List and billed at the minimum benefit rate (in accordance with the Private Health Insurance (Prostheses) Rules (Cth) rate current at the time of service.

Part 9: Requirements for billing for relevant services

38. Except where specified, the requirements below apply to billing in both the WC and CTP schemes.

39. In billing for the provision of relevant services, the RSP must:

(a) bill a fee similar to the amount customarily paid within the community for the type of service provided, where maximum fees for the service provided by the RSP is not established in a SIRA fees order made under ss61 – 63A of the Workers Compensation Act 1987 ^[9] (workers compensation scheme only)

(b) not charge a fee for cancellation or non-attendance by an injured person for treatment services

(c) not charge a fee for a relevant service unless it is directly payable to the RSP that has provided the treatment or related service or diagnostic procedure to an injured person, i.e. payment for services will not be provided to a third party or a referral service

(d) not bill a fee to provide a report to the referring general practitioner and a copy to the insurer when charging a subsequent consultation fee (surgical services)

(e) not bill a fee for surgical services consultation during routine aftercare following a surgical procedure, unless clinical justification is provided to the insurer

(f) not bill a fee for consultations conducted on the same day as planned surgery (the cost of these consultations is already included in the fee for the surgical procedure)

(g) not bill for a hearing-related aid and/or accessory unless the insurer is provided with a clinical justification as to how the hearing-related aid and/or accessory recommended is required to meet a hearing goal

(h) where provision of medical records has been requested, and the records have been stored electronically, they must be provided electronically and billed according to the maximum fee for provision of electronic records provided in the relevant SIRA fees order made under ss61 – 63A of the Workers Compensation Act 1987 ^[10] (workers compensation scheme only)

(i) for a report regarding the management of a person’s injury that is additional to any report routinely provided as part of consultation by a RSP, the RSP must:

• (i) have pre-approval from the insurer to provide and bill for the report; and
• (ii) bill for it according to the payment code for report writing from the relevant SIRA fees order made under ss61 – 63A of the Workers Compensation Act 1987 ^[11], prorated to accurately reflect the time taken to prepare the report. The RSP must not bill for it using a fee item from the Workplace Injury Management and Workers Compensation (Medical Examinations and Reports Fees) Order 2022 or the version of that fees order in effect at the time
• (iii) the above apply to the workers compensation scheme only.

j) bill for a case conference only where (workers compensation scheme only):

• (i) the purpose of the case conference is to clarify the person’s capacity for work, barriers to return to work, and strategies to overcome these barriers (ie. not to discuss treatment) to ensure parties share the same expectations about the person’s recovery at work or return to suitable employment
• (ii) the case conference is attended by the treating health service provider and any or all of the following:
  • the employer
  • the workplace rehabilitation provider
  • an injury management consultant
  • the insurer
  • other treatment practitioner/s delivering services to the person (including the nominated treating doctor)
  • the injured person if there is at least one other attendee from this list
• (iii) the health service provider organising the case conference
  • retains file notes of the case conference, including date, duration, participants, topics and outcomes. This information may be required for invoicing or auditing purposes
  • permits the injured person to bring a support person to a case conference if they wish to do so.

(k) not bill for use of a Consultation C item ^[12] (physiotherapy, chiropractic, osteopathy and exercise physiology services only, and workers compensation scheme only) unless:

• (i) two or more evidence-based risk screening/standardised outcome measures relevant to the clinical presentation are documented to demonstrate the complexities of the case and the clinical rationale for delivery of a Consultation C, and they are used to measure outcomes and demonstrate effectiveness of Consultation C treatment
• (ii) the provider reduces Consultation C duration time over time and transitions to a subsequent consultation as the workers progresses towards self-management and independence.

(l) not bill for travel costs:

• (i) unless it has been pre-approved by the insurer
• (ii) unless the reasonable travel charge has been divided evenly between claims where multiple workers are being treated in the same visit to a facility or in the same geographical area on the same day
• (iii) if the relevant services are provided on a regular or contracted basis to facilities such as a private hospital
• (iv) if the relevant services are provided by a provider who does not have a commercial place of business for the delivery of treatment services (for example, the provider has a mobile practice).

(m) not bill to amend a report provided by an RSP to correct an obvious error when the correction has been requested in writing by the referrer.

Invoicing requirements for relevant services, excluding pharmacy services (workers compensation scheme only)

40. Invoices for relevant services rendered must:

(a) be submitted within 30 calendar days of the service provided and must be itemised in accordance with relevant SIRA fees order/s (if fees order/s apply to the services delivered) and comply with the SIRA’s itemised invoicing requirements.

(b) include:

• (i) the injured person’s first and last name, and claim number
• (ii) payee details
• (iii) ABN
• (iv) name of the relevant health provider who delivered the relevant service
• (v) in the case of medical services, the providers:
  • Australian Health Practitioner Regulation Agency (AHPRA) number, and
  • Medicare provider number (unless not registered with Medicare)
• (vi) in the case of allied health services, the providers:
  • (SIRA approval number (where applicable), and
  • AHPRA number/professional association accreditation/membership number
• (vii) date of service
• (viii) relevant SIRA payment classification code or Australian Medical Association (AMA) Fees List item number where applicable
• (ix) service cost for each SIRA payment classification code or AMA item number and service duration (if applicable)
• (x) date of invoice (must be on the day of or after last date of service listed on the invoice)
• (xi) in the case of allied health services provided interstate, the service provider number INT0000 must be included on the invoice in addition to either the AHPRA number, or where the profession doesn’t have AHPRA registration, the professional association accreditation number, or peak association membership number
• (xii) in the case of allied health services provided to exempt workers, the service provider number EXT0000 must be included on the invoice in addition to either the AHPRA number, or where the profession doesn’t have AHPRA registration, the professional association accreditation number, or peak association membership number.

Invoicing requirements for pharmacy services

41. In the provision of relevant services, an invoice for relevant services from a registered pharmacy must include the following information:

(a) Pharmacy name and street address

(b) Dispensing pharmacist’s name

(c) Date of service (date dispensed)

(d) PBS item code (for PBS dispensed medications)

(e) A copy of the original script for medications that are available on the PBS but are dispensed privately (non-PBS), and a copy of the repeat prescription where applicable

(f) Full description of the medication (including script number, brand name, form)

(g) Quantity of medication dispensed

(h) Strength of the medication dispensed

(i) Prescriber name/address/prescriber number

(j) Amount charged per item.

Appendix A

(Extract from the State Insurance and Care Governance Regulation 2021)

4A Relevant services—the Act, s 26A

(1)  For the Act, section 26A, definition of relevant service, the following services are prescribed—

• (a)  audiology and audiometry services,
• (b)  Chinese medicine services,
• (c)  chiropractic services,
• (d)  counselling services,
• (e)  dental services,
• (f)  dietetics and nutrition services,
• (g)  exercise physiology services,
• (h)  massage therapy services,
• (i)  medical radiation practice services,
• (j)  medical services,
• (k)  nursing services,
• (l)  occupational therapy services,
• (m)  optometry services,
• (n)  osteopathy services,
• (o)  patient transport services,
• (p)  pharmaceutical services,
• (q)  physiotherapy services,
• (r)  podiatry services,
• (s)  psychology services,
• (t)  rehabilitation services,
• (u)  social work services,
• (v)  speech therapy services,
• (w)  services provided to injured persons relating to the provision and maintenance of aids, appliances or prostheses, including the following—
  • (i)  artificial body parts or other artificial aids,
  • (ii)  aids for activities of daily living,
  • (iii)  mobility aids,
  • (iv)  equipment provided as part of treatment or therapy services,
• (x)  domestic assistance services provided to injured persons, including household cleaning and laundry, lawn or garden care and transport services,
• (y)  private hospital and day surgery services, including in-patient and out-patient services,
• (z)  workplace rehabilitation services,
• (za) services provided by a health practitioner, not involving treatment, consisting of—
  • (i)  a medical opinion on the treatment or cause of an injury, or
  • (ii)  an assessment of a permanent impairment, or
  • (iii)  a peer review, or
  • (iv)  facilitating discussions between an injured person and doctors, insurers, employers and other service providers to manage the rehabilitation of the injured person,
• (zb) administrative services relating to the following—
  • (i)  referrals, including receiving referrals from or making referrals to, or on behalf of, a health practitioner,
  • (ii)  administrative functions associated with producing medical evidence relating to a person’s injury, functioning or impairment,
  • (iii)  access to medical documents, including medical certificates or radiology or medical imaging,
  • (iv)  centralisation or coordination of referrals or appointments and other administrative functions,
• (zc) medication management and review, including the assessment and analysis of medication use, cost and prescriber behaviour.

(2)  Subsection (1)(zb) does not include administrative services relating to the provision of legal advice to, or representation of, an injured person regarding a claim or dispute under the workers compensation and motor accidents legislation.

Appendix B

(Extract from the State Insurance and Care Governance Act 2015)

26D Directions concerning relevant services by relevant service providers

(1)  SIRA may give 1 or more of the following written directions to a relevant service provider—

• (a)  a direction requiring the provider to take specified action, or provide specified information, concerning specified relevant services,
• (b)  a direction requiring the provider to provide specified relevant services for the purposes of the workers compensation and motor accidents legislation in a specified way,
• (c)  a direction requiring the provider not to provide specified relevant services for the purposes of the workers compensation and motor accidents legislation,
• (d)  a direction requiring the provider not to provide any relevant services for the purposes of the workers compensation and motor accidents legislation.

(2)  Without limiting subsection (1), a direction under this section may extend to all of the workers compensation and motor accidents legislation or be limited to specified Acts or instruments, or specified provisions of Acts or instruments, forming part of the legislation.

(3)  A relevant service provider must comply with a direction given to the provider under this section.

Maximum penalty—

• (a)  for a corporation—500 penalty units, or
• (b)  for another person—100 penalty units.

(4)  The regulations may make provision for or concerning the following—

• (a)  the giving and form of directions under this section,
• (b)  the circumstances in which directions may be given under this section,
• (c)  the periods during which directions under this section have effect, including providing for directions of indefinite duration,
• (d)  standard provisions for directions under this section, including enabling standard provisions to be incorporated in directions by reference rather than set out in the directions,
• (e)  the revocation and variation of directions given under this section,
• (f)  appeal or review procedures for directions given under subsection (1)(a) or (b).

Note—

Section 26F allows a relevant service provider to apply to the Civil and Administrative Tribunal for an administrative review under the Administrative Decisions Review Act 1997 of a direction under subsection (1)(c) or (d).

_{[1] Note that this requirement also applies to treating health practitioners in the WC scheme under s60(2A)(d) of the Workers Compensation Act 1987. Inclusion here is intended to extend the requirement to other RSPs including RSPs working in the CTP scheme.}

_{[2] SIRA (2021), Value-Based Healthcare Outcomes Framework for the NSW Workers Compensation and Motor Accident Injury/Compulsory Third Party Schemes.}

_{[3] The Guidelines adopt the terms ‘remote’ and ‘very remote’ as described in the Australian Bureau of Statistics Australian Standard Geographical Classification System.}  

_{[4] Page 20, Virtual Care in Practice, NSW Agency for Clinical Innovation.}

_{[5] In the workers compensation scheme, pre-approval from the insurer is not required for dispensed prescription drugs and over-the-counter pharmacy items prescribed for the injury by the nominated treating doctor or medical specialist for the first month from date of injury – see the Workers Compensation Guidelines Part 4, Table 4.1.}

_{[6] Schedule 8 of the Poisons Standard October 2022, or the Poisons Standard in effect at the time.}

_{[7] Note that this is already a requirement for health practitioners authorised to give evidence in  court and other dispute resolution proceedings in the CTP scheme under Part 8 of the Motor Accident Guidelines. Health practitioners authorised to give evidence in court and other dispute resolution proceedings in the CTP scheme should refer to Part 8 of the Motor Accident Guidelines.}

_{[8] Note that there are requirements for approved allied health providers in Part 4.3 of the Workers Compensation Guidelines.}

_{[9] All SIRA WC fees orders are published on the SIRA website.}

_{[10] As above}

_{[11] As above}

_{[12] For definition see the SIRA publications “Physiotherapy, Chiropractic and Osteopathy Fees and Practice Requirements” and “Accredited Exercise Physiology Fees and Practice Requirements” in effect at the time. These publications are available on the SIRA website.}