What is the regulation about?
SIRA is consulting on a draft regulation about health services in the workers compensation and CTP schemes.
The majority of health services are provided to injured people with expert care and in compliance with the worker's compensation and CTP legislation. But there are outlier providers who aren't, and mechanisms to deal with them are required.
The draft supports legislative amendments made earlier this year
The draft State Insurance and Care Governance Amendment Regulation 2022 supports amendments made recently to the State Insurance and Care Governance Act 2015 (SICG Act) to give SIRA power to (amongst other things) direct relevant service providers to:
- supply SIRA with claim-related data and information
- take specified action or to provide relevant services to injured persons in a specified way
- not provide some or all relevant services to injured persons.
What’s the aim of the legislation and the regulatory framework?
The aim is that healthcare services provided to injured workers and road users in the workers compensation and CTP schemes are:
- appropriate, timely and cost effective
- contribute directly to improving health outcomes.
In what circumstances can SIRA make a direction?
The draft regulation provides that SIRA may give a direction if a relevant service provider has not complied with:
- the workers compensation and motor accidents legislation
- guidelines issued under the SICG Act, workers compensation or motor accidents legislation
- an ethical or professional standard
- SIRA believes the service provider poses a risk to injured people, or reasonably believes a direction is required.
How does SIRA intend to implement the regulation?
SIRA will take a stepped approach to dealing with non-compliance. Steps that SIRA can take, before using a direction include:
Assisting, supporting, and educating
- Provide guidance and support to providers about correct or best practice.
Notifying and advising
- Issue an ‘awareness letter’ to providers who continue to demonstrate non-compliance or poor performance.
- Continue to provide support through building knowledge and capabilities.
Escalated notification and targeted action
- Issue a ‘warning letter’ or ‘show cause letter’ to providers with ongoing non-compliance/poor performance.
Enforcement action
- Issue a direction under s26D (a direction to do, or not to do, something) or s26C (to provide data) to enforce the regulatory framework.
- Publish the providers name on the register with details regarding the direction made under s26D.
These steps will provide service providers with a reasonable opportunity to meet the requirements before a direction is issued and published on the register.
For directions about service provision, providers will be able to apply for an internal review or appeal the decision to NSW Civil and Administrative Tribunal.
| Step | Example of how SIRA would implement the stepped approach, in response to a notification of concern about a health practitioner |
|---|---|
| 1 | SIRA is notified of concerns about an allied health provider billing over the gazetted fee for the services provided. |
| 2 | SIRA assists and supports the allied health provider to correct their error by providing guidance about correct practice according to the relevant fees order. [Note: It is expected that the majority of cases would end here] |
| 3 | However, the allied health provider’s billing continues to be non-compliant. SIRA sends the provider an ‘awareness letter’ and provides further support to build their knowledge and capabilities. |
| 4 | If the allied health provider continues to charge incorrectly, they may be issued with a ‘warning letter’ or a ‘show cause letter”, advising them that SIRA can issue a direction that may restrict their ability to practice in both the WC and CTP schemes. |
| 5 | If non-compliance continues after these steps, SIRA may issue a formal direction to the allied health practitioner that (for example) they cannot practice in the schemes for a period of six months. If a direction is issued, the allied health provider’s name and the restriction is published on the directions register on SIRA’s website. |
| 6 | If the allied health provider does not comply with the direction, they will have committed an offence and a monetary penalty notice may be issued. |
Supporting guidelines
Guidelines will outline SIRA’s expectations of providers who provide relevant services. SIRA will consult on draft guidelines in November. The guidelines will spell out the practices or standards health practitioners must comply with. These may include:
- billing and servicing
- health service delivery, such as those in the Clinical Framework for the Delivery of Health Services
- codes of conduct.
What’s the purpose of the consultation?
- To obtain feedback and input on the draft regulation from the public and industry experts
- To identify unintended consequences of the drafting
- To identify matters for inclusion in the guidelines (draft to be published for consultation in November 2022)