Medical, hospital and rehabilitation
Workers can claim a range of expenses relating to medical treatments, hospital treatment, ambulance services and rehabilitation.
Treatment and services
Expenses relating to medical and hospital treatment, ambulance services and rehabilitation can be paid where the treatment or service:
- meets the definitions described in section 59 of the Workers Compensation Act 1987 (the 1987 Act)
- is reasonably necessary because of the work-related injury (see ‘What is reasonably necessary?' below)
- is pre-approved by the insurer, unless the treatment or service is exempt from pre-approval (see ‘Pre-approved treatment’ below)
- is administered by a person who is appropriately qualified to provide the treatment
- takes place while the worker is entitled to receive compensation for medical, hospital and rehabilitation expenses.
‘Medical or related treatment’ includes:
- treatment provided by a:
- medical practitioner
- SIRA-approved chiropractor
- dentist or dental prosthetist
- SIRA-approved physiotherapist
- SIRA-approved osteopath
- SIRA-approved exercise physiologist
- speech therapist
- massage therapist
- treatment given by direction of a medical practitioner
- the supply of crutches, artificial members, eyes or teeth, and other artificial aids or spectacles
- any nursing, medicines, medical or surgical supplies, or curative apparatus provided to the worker (other than as hospital treatment)
- care (other than nursing care) of a worker in the worker’s home directed by a medical practitioner having regard to the nature of the worker’s incapacity
- domestic assistance services
- the modification of a worker’s home or vehicle directed by a medical practitioner having regard to the nature of the worker’s incapacity
- treatment prescribed by the regulations as ‘medical or related treatment’ (excluding ambulance service, hospital treatment or workplace rehabilitation)
- hospital treatment at any hospital (or at any rehabilitation centre conducted by a hospital) including:
- patient maintenance
- the supply of nursing attendance, medicines, medical or surgical supplies, or other curative apparatus, and any other ancillary service
- ambulance services to convey a worker to or from a medical practitioner or hospital
- workplace rehabilitation service delivered by an approved rehabilitation provider.
A worker who needs to travel for an approved treatment or service is also entitled to reimbursement for necessarily and reasonably incurred fares, travel expenses and maintenance.
Workers are not entitled to travel expenses for treatment or services provided at a location that requires more travel than is reasonably necessary to obtain the treatment or service.
If the worker is unable to travel unescorted, then the fares, travel expenses and maintenance costs necessarily and reasonably incurred by the worker’s escort, are also payable by the insurer.
Workers can claim medical, hospital and rehabilitation expenses during the ‘compensation period’. This period starts from the date of injury and continues after the cessation of weekly payments, depending on the worker’s level of assessed permanent impairment. If no weekly payments were made, the compensation period begins from the date of claim.
|Eligibility criteria||Entitlement period|
|Workers with no permanent impairment assessment or permanent impairment assessed as 1-10%|
Two years from:
|Workers with permanent impairment assessed as 11-20%|
Five years from:
Workers with high needs. This refers to workers:
|All workers||Lifetime entitlement for crutches, artificial members, eyes or teeth and other artificial aids or spectacles, including hearing aids and hearing aid batteries, home or vehicle modifications.|
Secondary surgery is available for all eligible workers. Surgery is secondary surgery if:
Further information on medical entitlement periods can be found in 'End of medical entitlements'.
Generally, workers must obtain insurer approval before starting treatment. There are however, some exceptions to this rule. These are outlined in ‘Pre-approved treatment’ below.
When approving treatment, the insurer will consider the following questions:
- Does the treatment/service meet the definitions described in section 59 of the 1987 Act?
- Will the treatment/service take place while the worker is entitled to receive compensation (the compensation period) for medical, hospital and rehabilitation expenses?
- Is the treatment/service for the compensable injury?
- Is the treatment/service reasonably necessary? (See ‘What is reasonably necessary?’ below.)
What is reasonably necessary?
When approving or paying for a medical, hospital or rehabilitation treatment or service, the insurer will determine (based on the facts of each case) whether the treatment/service is ‘reasonably necessary’.
The Workers compensation guidelines (the Guidelines) state that:
- what is determined as reasonably necessary for one worker may not be reasonably necessary for another worker with a similar injury
- reasonably necessary does not mean absolutely necessary
- although evidence may show that a similar outcome could be achieved by an alternative treatment, it does not mean that the treatment recommended is not reasonably necessary.
The insurer may also consider the following:
- the appropriateness of the particular treatment
- the availability of alternative treatment
- the cost of the treatment
- the actual or potential effectiveness of the treatment
- the acceptance of the treatment by medical experts.
Facilitating treatment approval
The worker and/or treatment providers can support a treatment request by supplying additional information to the insurer so they can determine whether the treatment/service is reasonably necessary.
The following documents may be useful when determining treatment approval:
- a certificate of capacity recommending the proposed treatment
- a letter or report from the nominated treating doctor
- allied health recovery requests or reports
- specialist referrals or reports
- investigation/diagnostic reports.
If the insurer has any concerns or queries regarding the treatment proposed they should contact the nominated treating doctor or allied health professional to discuss it.
A referral for an independent medical examination cannot be made unless reasonable attempts to discuss treatment have been made.
Getting a second opinion
Insurers can offer, and workers can request, approval to obtain a second opinion on recommended treatment. Once approved, the nominated treating doctor can arrange a referral to another specialist.
A second opinion can help a worker make a decision about a treatment option or provide comfort in a diagnosis.
Timeframe for treatment approval
Timely approval of treatment will facilitate early recovery and help in the return to work process.
All treatment requests must be determined within 21 days of receipt.
Treatment approval should be provided to the worker in writing (for example, a signed request or email). The insurer should also call the worker so treatment can commence as soon as possible.
If a practitioner already treating the worker is requesting further treatment using an allied health recovery request (AHRR), the insurer is to respond within five days of receiving it.
If the insurer does not respond within five days (in the first three months post injury), the request is automatically approved. The allied health practitioner must be able to demonstrate the AHRR has been lodged. Further information on treatments using an AHRR can be found in 'Allied health practitioners'.
When treatment is not approved, a decision notice is required to be issued to the worker. If a worker is unhappy with a decision made regarding their treatment they can begin the dispute resolution process. See 'Resolving complaints and disputes’ for information on the worker’s right to a review of the decision.
If the insurer disputes liability for treatment, they are not liable for the costs of that treatment after the date the worker was notified in writing of the decision to deny liability.
This information does not apply to exempt workers
The Guidelines specify the treatment services that do not require insurer approval before they begin. These are provided in the Guideline tables 4.1 and 4.2, as shown below:
Medical and hospital treatment
Table 4.1 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 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|
If referred by the nominated treating doctor, any consultation and treatment during consultations for the injury. 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|
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:
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|
Allied health treatment
Table 4.2 Other treatments and services available without pre-approval from the insurer
SIRA-approved allied health practitioners1:
|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:
|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:
Note: Hearing needs assessment includes:
1 AHPs which meet the requirements of SIRA’s Approval Framework under s60(2C)
Treatment provided without pre-approval
Insurers may use their discretion to approve payment of treatment that is provided without pre-approval.
The insurer will consider whether the treatment was reasonably necessary and would have been approved had approval been sought. They may also assess the impact of the treatment on the worker’s recovery and return to work in the decision-making process.
There is no requirement for exempt workers to seek pre-approval for treatment however exempt workers should be aware that expenses are not payable if not later approved by the insurer.
SIRA recommends that exempt workers work with their insurer to avoid incurring expenses that may not be paid.
Payment for medical and related services
Most common medical and treatment costs are covered by a gazetted Fees Order.
To work out how much to pay for these treatments or services, the insurer should use the relevant SIRA Workers Compensation Fees Order found on the SIRA website.
Each Fees Order contains a schedule that sets out what services can be provided and the maximum gazetted amount that can be reimbursed for a medical treatment or service.
A worker is not to pay any amount above the maximum set by SIRA.
For treatments or services not covered by a Fees Order, the insurer will agree on a fee with the provider beforehand, based on what the community would normally pay. The insurer will specify these costs when notifying the worker and provider of its approval.
Reimbursement for travel
Travel reimbursement for personal vehicle travel is to be paid at the rate specified in the Workers compensation benefits guide (currently 0.55c per kilometre).
Insurers reimburse worker public transport costs using the receipts provided by the worker.
If a taxi is required, this is to be arranged by the insurer beforehand.
In most cases, the provider will forward an invoice directly to the insurer.
To make payment, the insurer should ensure the invoice includes the following information:
- worker’s first and last name
- worker’s claim number
- date of service
- date of invoice (must be on the day of, or after the last day of service listed on the invoice)
- SIRA payment classification number or AMA item number where applicable
- cost for each SIRA payment classification number or AMA item number, and duration (where applicable)
- payee details
- name of the medical practitioner or service provider who provided the service
- SIRA approval number or medical practitioner’s Health Insurance Commission number (where applicable).
The insurer is expected to pay invoices promptly.
Further information on insurer requirements can be found in Standard of practice S10. Payment of invoices and reimbursements.
If a worker has paid an account and is claiming reimbursement, the insurer requires a tax invoice that meets the requirements specified in ‘Invoices’ above.
In addition, evidence, such as an official receipt, is required to demonstrate that the invoice has been paid. The insurer is expected to pay reimbursements promptly.
Further information on insurer requirements can be found in Standard of practice S10. Payment of invoices and reimbursements.
Treatment for non workers compensation conditions
A worker may require management and treatment for a non work injury or illness at the same time as requiring management and treatment of a compensable condition (for example, pre-existing depression and a work-related knee injury).
The nominated treating doctor may treat both conditions during the same consultation but should manage each separately, including separate billing and separate certificates – a SIRA certificate of capacity for the work-related condition, and a normal medical certificate for the non work condition (if required).
Consideration should be given to the holistic treatment of the worker to facilitate recovery and return to work.
Treatment and return to work
Once a worker has returned to work, they may need to negotiate with their employer about whether they attend medical appointments in their own time or in work hours.
Many employers may already have written policies and procedures outlining these expectations for their workers. This information is usually contained in the employer’s return to work program.
If the employer does not have any documented policies and procedures, expectations should be discussed as soon as practicable.
It is expected that wherever possible, workers should obtain approved medical treatment outside of normal working hours, however this may not always be possible.
Factors to consider include:
- the number of hours the worker works each week
- the availability of the treatment provider to see the worker outside of working hours
- the amount of time if would take to travel to the appointment (especially for rural and remote workers)
- workplace business requirements.
Questions regarding treatment
If the insurer has questions regarding any treatment being provided they should, in the first instance, contact the treatment provider or nominated treating doctor directly.
If the information is inadequate or inconsistent, or they are unable to obtain the required information, a referral to an independent consultant or an independent medical examiner may be required.
- Certificate of capacity / certificate of fitness form
- Information on the certificate of capacity/certificate of fitness
- Fees and rates orders
- Workers compensation benefits guide
- Clinical Framework for the Delivery of Health Services
- Workers compensation guide for allied health practitioners
- Allied health recovery request
- Workers Compensation Commission
- AMA presentation on the role doctors play in the NSW workers compensation system