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Appendix 2: Practice guidance - Pre-approval of treatment

Application to exempt workers

There is no requirement for exempt workers to seek pre-approval for treatment, however exempt workers should be made aware that treatment and services may not be payable without insurer approval.

The payment of treatment and services for exempt workers should be assessed with consideration to whether:

  • the treatment or service is required as a result of the injury
  • the treatment or service is considered reasonably necessary, and
  • the provision of costs has been properly verified.

Overview

Section 60(2A) of the 1987 Act states that an employer is not liable for any medical treatment or service, or related travel expenses, if:

(a) the insurer has not granted prior approval for the treatment or service. This does not include:

- treatment provided within 48 hours of the injury happening

- treatment which is exempt from the requirements of prior insurer approval as outlined in the Workers compensation guidelines (the Guidelines).

(b) the person is not appropriately qualified to provide the treatment or service

(c) the treatment or service is not in accordance with the conditions outlined in the Guidelines, or

(d) the treatment is given or provided by a health practitioner whose registration is limited or subject to any condition imposed as a result of disciplinary process, or who is suspended or disqualified from practice.

The Guidelines detail exemptions from insurer pre-approval (refer to Part 4, Tables 4.1 and 4.2). These tables are reproduced below.

Reasonably necessary treatments and services available without pre-approval from the insurer

TreatmentExpenseTimeframe from date of injury
Initial treatmentInitial treatmentWithin 48 hours
Nominated treating doctorConsultation or case-conferencing for the injury, apart from telehealth and home visitsOngoing
Treatment during consultationWithin one month
Public hospitalServices provided in the emergency department for the injuryOngoing
Further services after receiving treatment at the emergency department for the injury.Within one month
Medical specialists

If referred by the nominated treating doctor, any consultation and treatment during consultations for the injury (apart from telehealth). Referrals for diagnostic tests must meet the Medicare Benefits Schedule criteria.

Note: Medical specialist means a medical practitioner recognised as a specialist by the Australian Health Practitioner Regulation Agency and remunerated at specialist rates under Medicare.

Within three months
Diagnostic investigations

If referred by the nominated treating doctor for the injury:

  • any plain x-rays.
Within two weeks

If referred by the nominated treating doctor, and the worker has been referred to a medical specialist for further injury management:

  • ultrasounds and CT scans
  • MRIs.

Note: General Practitioners must satisfy the Medicare Benefits Schedule criteria when making a referral for an MRI.

Within three months
If referred by the treating medical specialist for the injury, any diagnostic investigations.Within three months

Pharmacy

Dispensed prescription drugs and over-the-counter pharmacy items prescribed for the injury by the nominated treating doctor or medical specialist.

Within one month

Prescription drugs and over-the-counter pharmacy items prescribed for the injury and dispensed through the Pharmaceutical Benefits Scheme (PBS)Ongoing

Other reasonably necessary treatments and services available without pre-approval from the insurer

TreatmentExpense

SIRA-approved allied health practitioners[1]:

  1. Physical practitioners (physiotherapists, osteopaths, chiropractors, accredited exercise physiologists)
  2. Psychological practitioners (psychologists and counsellors)
Up to eight consultations if the injury was not previously treated by a provider from the same allied health practitioner group (either 1. Physical or 2. Psychological) and the treatment begins within three months of the injury

Up to eight consultations per Allied health recovery request (AHRR) if the same practitioner is continuing treatment within three months of the injury and:

  • the practitioner sent an AHRR to the insurer, and
  • the insurer did not respond within five working days of receiving the AHRR.
Up to three consultations if the injury was not previously treated by a provider from the same allied health practitioner group (either 1. Physical or 2. Psychological) and the treatment begins more than three months after the injury
One consultation with the same practitioner if the practitioner previously treated the injury more than three months ago. This is considered a new episode of care.
One consultation with a different practitioner if the injury was previously treated by a provider from the same allied health practitioner group (either 1. Physical or 2. Psychological).
Up to two hours per practitioner for case conferencing that complies with the applicable Fees Order.
Up to $110 per claim for reasonable incidental expenses for items the worker uses independently at their home or workplace (such as strapping tape, theraband, exercise putty, disposable electrodes and walking sticks).
Interim payment directionAny treatment or service under an interim payment direction from the Registrar (or delegate) of the Workers Compensation Commission as outlined in section 297 of the 1998 Act.
Commission determinationAny disputed treatment or service the Workers Compensation Commission has determined must be paid.
Permanent impairment medical certificatePermanent impairment medical certificate or report, and any associated examination, taken to be a medical-related treatment under section 73(1) of the 1987 Act.
Hearing needs assessment

The initial hearing needs assessment where the:

  • hearing service provider is approved by SIRA, and
  • nominated treating doctor has referred the worker to an ear, nose and throat medical specialist, to assess if the hearing loss is work-related and, if applicable, the percentage of binaural hearing loss.

Note: Hearing needs assessment includes:

[1] Allied health practitioners that meet the requirements of SIRA’s approval framework under section 60(2C), 1987 Act.

The exemptions outlined in the Guidelines only apply where provisional liability for medical expenses or liability for a claim has been accepted.

Informing workers and service providers of approval

Workers should receive prompt treatment and medical services without unnecessary delay.

Where treatment may be necessary for the worker, the insurer should inform the worker (and service provider, where appropriate) of treatments or services that do not require pre-approval. This can form part of the injury management process and the initial conversations between the insurer and the worker/provider about how to achieve the best outcome.

The insurer should also make sure other relevant parties, including the employer and nominated treating doctor, are appropriately informed.

Workers should not be made to pay for treatment and medical services directly. Where the worker has received treatment or services and has paid the invoice directly, the insurer is expected to promptly reimburse the worker as required by ‘Standard of practice 10: Payment of invoices and reimbursements’.

Disputed matters

The Workers Compensation Commission (the Commission) can make an interim payment direction under section 297 of the 1998 Act.  Where a medical dispute is referred for an interim payment direction, then the insurer must pay for the treatment or services if directed by the Commission to do so.

The maximum amount payable under an interim payment direction is indexed, with the amounts updated bi-annually in SIRA’s Workers compensation benefits guide.

Under the Guidelines, an insurer is required to pay for a treatment or service determined by the Commission to be reasonably necessary, regardless of whether or not the worker sought pre-approval of the treatment or service.

Medical treatment and services requiring prior approval

Medical treatment and services not listed in the Guidelines require approval from the insurer before they are provided. When considering a request for treatment, the insurer should consider the following questions:

  • Is the treatment or service captured by one of the definitions described in section 59 of the 1987 Act?
  • Will the treatment or service take place while the worker is entitled to receive compensation (the compensation period) for medical, hospital and rehabilitation expenses?
  • Is the treatment or service reasonably necessary as a result of the injury? (see Part 4.2 of the Guidelines)

If the insurer has any concerns or queries regarding the treatment proposed, they should contact the medical provider to discuss and resolve the issue(s) directly.

There may be instances where a referral to an independent medical examiner (IME) is appropriate. The Guidelines provide that referral is appropriate when information from the treating medical practitioner(s) is inadequate, unavailable, or inconsistent, and the insurer is unable to resolve the problem directly with the practitioner. Reasons for referral are detailed in Part 7.1 of the Guidelines.

Timeframe for treatment approval

Insurers are to determine treatment approval as soon as possible after receiving a request. All treatment requests must be determined within 21 days of receipt. See ‘Standard of practice 4: Liability for medical or related treatment’ and section 279 of the 1998 Act for further information.

If a treating practitioner requests further treatment using an allied health recovery request (AHRR), and it is within three months of the injury, insurers are required to respond within five days of receiving it. If the insurer does not respond within five days, the request is automatically approved. The allied health practitioner must be able to demonstrate the AHRR was lodged with the insurer in these instances.

Treatment approval should be provided to the worker in writing (for example, a signed AHRR or email). The insurer should also call the worker and employer (where appropriate) so treatment can commence as soon as possible. Informing the treatment practitioner and other relevant stakeholders will also help the management of treatment.

Disputing treatment

Any decision to dispute liability for treatment should be made in accordance with the legislation and in the context of the claim in its entirety. It should also follow appropriate and sound decision-making process and procedural fairness.

When a treatment or service is not approved, a dispute notice is to be issued to the worker, as required by section 78 of the 1998 Act. Informing the treatment practitioner and other relevant stakeholders will assist with the management of the worker’s claim.

It is at the insurer’s discretion to approve payment of reasonably necessary treatment that is provided without prior approval.