Claims and injury management

Overview

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

1. 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 Part 4 of the Workers compensation guidelines (the Guidelines).
2. the person is not appropriately qualified to provide the treatment or service
3. the treatment or service is not in accordance with the conditions outlined in the Guidelines, or
4. 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.

This guidance outlines important information in relation to:

• accessing treatment without insurer pre-approval
• medical treatment and services which require pre-approval
• informing workers and service providers of approval for treatment
• disputing treatment.

Accessing treatment without pre-approval

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

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

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

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

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 S4. 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.

Informing workers and service providers of approval

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 S10. Payment of invoices and reimbursements.

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 Workplace Injury Management and Workers Compensation Act 1998 (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.

Disputed Matters

The Personal Injury 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.