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Doctors in Workers Comp

Evidence shows staying at work or returning to work promotes recovery and leads to better health outcomes. In most cases, this means getting back to good work is an important part of recovery.

In brief

Doctors play an important role in the facilitation of treatment and recovery for a worker following a workplace injury.

Doctors support a workers’ recovery by:

  • educating them on their injury and recovery options
  • where appropriate, recommending treatment to help in their recovery
  • acting as the primary contact for treatment and recovery information for their employer, the insurer and other parties involved in the management of their injury
  • applying the principles of the clinical framework for the delivery of health services.

It is important to work in collaboration with all parties involved in the management of the workers’ injury.

In the NSW workers compensation system the general practitioner (GP), specialist or surgeon is responsible for the ongoing management of a workers’ injury and is referred to as the nominated treating doctor (NTD). Apart from assessing, diagnosing, treating and certifying patients, the role of the NTD includes supporting the patient with their recovery at/return to work. This also involves contributing to recovery at/return to work planning in collaboration with the worker and other members of the support team.

Learn more about the role doctors play in the NSW workers compensation system with this AMA presentation.

Watch this video on how doctors and employers can work together to help a worker recover at work.

Surgeons

A surgeon is a medical practitioner who is currently:

This includes a surgeon who is a staff member providing services at a public hospital.

Orthopaedic surgeons

An orthopaedic surgeon is a medical practitioner who is currently:

This includes an orthopaedic surgeon who is a staff member providing services at a public hospital.

Medical specialists and consulting physicians

Practitioners recognised as specialists or consultant physicians under the Health Insurance Act may be involved in a worker’s injury management and recovery at/return to work.

Medical specialists may also be required to give an expert opinion to help in the assessment of a claim, or assist with a dispute or settlement. For more information see:

You can also contact us if you have any questions.

Medical certificates

SIRA has one medical certificate for both the workers compensation system and motor accident scheme. This is called the certificate of capacity/certificate of fitness. There is information to help you complete this document.

All patients should provide the insurer with a completed certificate of capacity/certificate of fitness to claim for workers compensation.

When completing the certificate of capacity/certificate of fitness it is important to consider:

  • the nature of the injury/illness
  • the diagnosis
  • the treatment required to assist with recovery from the injury/illness
  • the patient's capacity for work taking into consideration their capacity for other activities
  • proposed dates
  • any considerations or modifications in the home or workplace that may assist the worker with their recovery.

Fees and invoicing

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Get treatment approval first

If an insurer disputes liability, or declines a treatment request because it does not meet reasonably necessary criteria, the worker may be personally responsible for the payment of accounts.

Before commencing treatment, a doctor should contact the insurer to confirm they have an accepted workers compensation claim and the proposed treatment or service is approved.

Some treatment and services may not require pre-approval from the insurer. The Workers compensation guidelines 2019 provides clarification on accessing treatment without prior approval.

GPs providing treatment to workers in the NSW workers compensation system are paid in accordance with the Workers Compensation Medical Practitioner Fees Order

For a summary of the most commonly used GP codes please refer to the 2019 SIRA rates for general practitioners.

Treating medical specialists and physicians are paid in accordance with the Workers Compensation Medical Practitioner Fees Order.

The Surgeon Fees Order sets the current maximum fees for treatment by a surgeon, while the Orthopaedic Surgeons Fees Order sets the current maximum fees for orthopaedic surgeons. Fees Orders are reviewed every year.

What invoices need to include

  • worker's first and last name, and claim number
  • payee details
  • ABN
  • name of the medical practitioner or service provider who provided the service
  • SIRA workers compensation approval number or medical practitioner's Health Insurance Commission provider number (where applicable)
  • date of service
  • SIRA workers compensation payment classification code or AMA item number where applicable.
  • service cost for each SIRA workers compensation payment classification code or AMA item number and service duration (if applicable
  • date of invoice (must be on the day of or after last date of service listed on the invoice)

To prevent delays in payment, these details will need to be provided on all invoices.

Invoices should be submitted within 30 calendar days of the service being provided.

Invoicing for medical reports

When a medical practitioner receives a request for a medical report it’s important to clarify with the referring party the purpose of the request.

If the report is to provide an opinion in relation to a dispute or potential dispute in respect of a claim made by a worker, refer to the Workplace Injury Management and Workers Compensation (Medical Examinations and Reports Fees) Order. Reports by general practitioners and medical specialists have different maximum gazetted rates.

If the report is to provide information in relation to the routine medical management of a worker’s injury and/or matters relating to recovery at/return to work, refer to the Workers Compensation (Medical Practitioner Fees) Order . General practitioners, medical specialists and consulting surgeons have different hourly rates for this service as stated in the Fees Order. The medical practitioner should consult with the referring party to establish an agreed timeframe and the appropriate fee for completion of the requested report.

See also the 2018 Fees Orders for:

Workers Compensation Medical Practitioners

SIRA rates for general practitioners

Orthopaedic Surgeons