Medical and related services

Overview

Some workers will require surgery as part of their recovery and return to work.

Any surgery must be approved by the insurer beforehand, unless it is within 48 hours of the injury occurring.

This guidance outlines what insurers should consider when a request for surgery is received, including:

• information to be obtained when a request for surgery is made
• the timeframe within which liability is to be determined, and
• when a second opinion or independent medical examination should be considered.

The request for surgery

The surgeon recommending the surgery should make a request for approval and provide the following information:

• the reason surgery is required
• an outline of the conservative (non-surgical) management undertaken to date
• the expected outcome from surgery
• the name, item codes and costs for the surgery requested (including name and cost of any prosthesis required)
• whether a surgical assistant is required.

Surgical requests should be checked to determine they comply with provisions and fees stated in the relevant Fees Order/s.

The insurer should also clarify the:

• anticipated period of stay in hospital
• time of total incapacity expected
• treatment required after surgery
• anticipated progress after surgery.

When considering requests for surgery, the insurer is expected to work collaboratively with the worker and their treating practitioner. If the insurer has questions regarding the proposed surgery, these should be raised with the surgeon and/or the nominated treating doctor.

Approval of surgery is not to be delayed while obtaining this information.

Timeframes

Surgery requests are to be determined within 21 days - see section 279 of the Workplace Injury management and Workers Compensation Act 1998 (1998 Act).

If surgery is not approved, the insurer must give notice to the worker in accordance with section 78 of the 1998 Act within the 21-day timeframe. The notice must be issued in the prescribed format, and must be concise, understandable and provide reasons why the surgery was not approved. Refer to Insurer guidance GN 8.1 Insurer decisions and decision notice requirements for further detail regarding the decision notice.

If a request for urgent surgery is made, all reasonable efforts must be taken by the insurer to make a decision as soon as possible.

When a request for surgery appears on a certificate of capacity or medical certificate

If a request for surgery first appears within the ‘Management plan’ section of a certificate of capacity, the insurer should immediately follow-up with the nominated treating doctor to obtain further information to help determine whether the surgery is reasonably necessary.

Getting a second opinion

If the insurer is concerned that the treatment requested will not lead to optimal health outcomes, they should discuss this with the worker and treating practitioner. A second opinion should be considered and offered to the worker.

Workers may also ask the insurer for approval to attend a second opinion from another specialist regarding recommended treatment. Once the insurer provides approval, the nominated treating doctor can arrange referral to another specialist.

Independent medical examination

Insurers cannot request a referral for an independent medical examination (see Insurer guidance GN 6.8 Independent medical examinations) to help determine whether proposed surgery is reasonably necessary until reasonable attempts have been made to contact the worker’s surgeon, or relevant questions asked of the surgeon have not been adequately answered.

After surgery

The insurer should contact the worker following the surgery. The insurer will need to establish if the worker has any restrictions, and ensure they have appropriate support and care when discharged from hospital.

If the worker has a discharge summary with treatment and/or medication recommendations, the insurer should make sure the nominated treating doctor receives a copy.

An activities of daily living assessment may also be required. If so, this should be arranged as soon as possible to ensure the worker receives the appropriate support. The insurer and/or employer should maintain regular contact with the worker following surgery.

Fees and invoices

Fees

Separate Fees Orders exist for surgeons and orthopaedic surgeons. Fees Orders are gazetted annually.

The Fees Order specifies:

• the maximum amount payable for medical treatments and services carried out for workers compensation claims
• the codes treating specialists are to use (including any references to the Australian Medical Association’s List of Medical Services and Fees) when invoicing
• what various services include
• other provisions/rules in relation to invoicing for surgery
• that workers are not liable for these costs.

Invoices

Following a worker’s surgery, an insurer can expect to receive an invoice from the:

• surgeon
• anaesthetist
• hospital
• assistant at operation (where appropriate).

Invoices must meet SIRA invoicing requirements and should be submitted to the insurer within 30 calendar days of the treatment (See Insurer guidance GN 4.3 Invoices and reimbursements).