Appendix 2: Practice guidance - Pre-approval of treatment
| Application to exempt workers |
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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:
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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
| Treatment | Expense | Timeframe from date of injury |
|---|---|---|
| Initial treatment | Initial treatment | Within 48 hours |
| Nominated treating doctor | Consultation or case-conferencing for the injury, apart from telehealth and home visits | Ongoing |
| Treatment during consultation | Within one month | |
| Public hospital | Services provided in the emergency department for the injury | Ongoing |
| 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:
| Within two weeks |
If referred by the nominated treating doctor, and the worker has been referred to a medical specialist for further injury management:
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
| Treatment | Expense |
|---|---|
SIRA-approved allied health practitioners[1]:
| 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:
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| 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 direction | Any 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 determination | Any disputed treatment or service the Workers Compensation Commission has determined must be paid. |
| Permanent impairment medical certificate | Permanent 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:
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Note: Hearing needs assessment includes:
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[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.