S15. Approval and payment of medical, hospital and rehabilitation services

Commencement date: 21 October 2019

Prompt approval and payment for medical, hospital and rehabilitation services ensures workers can remain focused on their recovery and helps to maintain the integrity of the scheme.

Principle

Prompt consideration will be given to approving medical, hospital and rehabilitation services and payment will be made as soon as practicable after services are invoiced.

ExpectationsBenchmarks
S15.1

Before making a decision about approval for services, insurers are to determine:

  • whether the service provider is appropriately qualified to provide the service
  • whether the proposed fees are appropriate and/or consistent with workers compensation fees orders, and
  • whether the services requested align to appropriate billing/payment codes.

Evidence on claim file

S15.2When approving services from workplace rehabilitation providers, insurers are to ensure that services are consistent with the Guide: Nationally consistent approval framework for workplace rehabilitation providers and the NSW Supplement to the Guide.

Evidence on claim file or other operational documents/agreements

S15.3

Insurers are to review service provider invoices before payment and ensure:

  • rates and items billed align with approvals
  • rates do not exceed the maximum amount prescribed by any relevant workers compensation fees orders, and
  • invoices contain all relevant information, including application of GST or input tax credits where appropriate.

Evidence on claim file

Prompt approval and payment for medical, hospital and rehabilitation services ensures workers can remain focused on their recovery and helps to maintain the integrity of the system.

Insurers are responsible for the approval and payment for treatment and services during the worker’s claim.

Key to managing provider services is ensuring that the services under consideration are:

  • provided by an appropriately qualified provider
  • reasonably necessary because of the injury
  • cost-effective, and
  • progress or promote the worker’s recovery.

SIRA recommends considering the five principles outlined in the Transport Accident Commission (TAC) and Worksafe Victoria’s Clinical framework for the delivery of health services as an effective method to ensure active management of a provider. These principles require the provider to:

  • measure and demonstrate the effectiveness of the intervention
  • adopt a biopsychosocial approach
  • empower the person to manage their recovery
  • implement goals focused on optimising function, participation and return to work
  • base intervention on the best available research evidence.

Where the insurer is uncertain of the value of requested treatment or services they may seek guidance from a SIRA-approved independent consultant.

In approving services provided by a third-party, the insurer must ensure the injury management plan is updated where necessary. They must also actively engage all stakeholders to achieve the expected outcome from the approved service.

To ensure cost-effective service provision and payment in-line with legislative requirements, insurers should actively review billing and rates when paying for services.

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