Medical and related services

Approving surgery

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

All surgery must be approved by the insurer beforehand, unless it is within 48 hours of the injury occurring or provided by an emergency department at a public hospital.

The surgeon intending to perform the surgery must make the request for approval and provide the following information to the insurer:

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

All medical treatment requests are to be determined within 21 days.

If the insurer has questions regarding the proposed surgery these should be raised with the surgeon and/or the nominated treating doctor.

The insurer should also clarify the:

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

This information will help the insurer arrange any required assistance after surgery.

Getting a second opinion

A referral for a second opinion should be offered to the worker before a referral for an independent medical examination is considered. Once approved, the nominated treating doctor can arrange a referral to another specialist.

Referral to an independent medical examiner

Whenever possible, the insurer should contact the worker first by phone to discuss the need for an independent medical examination. A referral for an independent medical examination cannot take place until attempts have been made to contact the surgeon, and the surgeon has been provided with a reasonable opportunity to answer the relevant questions but has not done so.

Urgent surgery

If a request for urgent surgery is made, all reasonable efforts must be taken by the insurer to make a decision in the reduced timeframe.

After surgery

The worker may have additional needs after surgery. The worker and/or nominated treating doctor should discuss these with the insurer prior to the surgery so appropriate arrangements can be made.

Fees and invoicing

In most cases, the surgeon will forward an invoice directly to the insurer.

The surgeon is not permitted to directly bill the worker for services related to the claim.

Fees for medical specialists are set out in the Medical Practitioner Fees Order. There is a separate Fees Order for surgeons. Refer to the SIRA website.

The Fees Orders specify how much can be charged and what codes specialists are to use. Fees Orders specify the maximum amount payable per service and any service restrictions, and reiterate that workers are not liable for these costs.

No fees are payable for cancellation or non-attendances. Pre-payment of fees for reports or services is not permitted.

Invoices should include:

• the worker's first and last name, and claim number
• payee name, address, telephone number and email address
• payee Australian Business Number (ABN)
• name of the relevant service provider who delivered the relevant service
• in the case of medical practitioner services, the provider’s:
  • Medicare provider number (unless not registered with Medicare).
  • Australian Health Practitioner Regulation Agency (AHPRA) number
• in the case of invoices for surgery: a detailed operation report including a description of the initial injury and an outline of the mechanism of injury, time surgery commenced and finished, intra-operative findings and the procedures performed, including structures that were repaired (stating the anatomic location) and technique of repair
• relevant SIRA payment classification code or Australian Medical Association (AMA) Fee List item number (where applicable). Refer to the relevant Fees Order and the Workers Compensation Insurer Data Reporting Requirements.
• service cost for each SIRA payment classification code or AMA Fee List item number and service duration (if applicable).
• the date of service
• the date of invoice (must be on the day of or after last date of service listed on the invoice)

To prevent delays in payment, these details need to be provided on all invoices.