Guidelines for the Provision of Relevant Services (Health and Related Services)

About the Guidelines

Guideline-making powers

The Guidelines for the Provision of Relevant Services (Health and Related Services) (the Guidelines) are made under section 26E of the State Insurance and Care Governance Act 2015 (the Act), which provides that the State Insurance Regulatory Authority (SIRA) may issue guidelines concerning the provision of relevant services by relevant service providers (RSPs) as defined in section 26A of the Act.

Interpretation

The Guidelines are to be read and applied together with the relevant provisions of the:

a) State Insurance and Care Governance Act 2015 (the Act), the State Insurance and Care Governance Regulation 2021 (the Regulation), and

b) workers compensation legislation, the motor accident legislation and the regulations and guidelines made under those Acts.

Words defined in the Acts or the Regulations have the same meaning in the Guidelines.

Note: The motor accident legislation means the Motor Accident Injuries Act 2017

Commencement

The Guidelines will take effect and apply to the provision of relevant services by RSPs under the workers compensation legislation and motor accident legislation on and from 8 December 2023 until they are amended, revoked or replaced in whole or part.

Application of the Guidelines

RSPs must comply with applicable clauses in the Guidelines.

Table 1 in Part 8 sets out which Parts of the Guidelines apply to certain RSPs under the motor accident and workers compensation legislation.

Each Part of the Guidelines also includes a summary of the application of the Part to RSPs under the motor accident and workers compensation legislation.

RSPs will be afforded procedural fairness by SIRA when responding to non-compliance with the application of the Guidelines.

Purpose of the Guidelines

The purpose of the Guidelines is to establish:

a) a code of conduct

b) service standards and requirements for RSPs in relation to specific relevant services, and

c) invoicing and billing requirements for RSPs.

Compliance with the Guidelines

SIRA will monitor and review compliance with the Guidelines in line with its statutory functions.

Part 1: Code of conduct

1.1 An RSP must provide relevant services in a manner that complies with the code of conduct set out in clause 1.2.

1.2 An RSP is to:

a) be appropriately registered, accredited, hold appropriate professional membership, and be qualified and experienced to provide the relevant service

b) act in a professional, ethical, honest, and impartial way

c) treat an injured person with empathy, respect, and culturally safe practice

d) comply with relevant provisions of the Guidelines, and relevant provisions of the workers compensation and motor accident legislation and the regulations and guidelines made under those Acts

e) not engage in overservicing or engage in behaviour that leads to overbilling or delivering more services than necessary

f) not provide, bill, or refer for relevant services, in a misleading or deceptive way intended to result in financial or personal gain of the RSP or another person or entity where the RSP or the other person is not entitled to the financial or personal gain

g) identify perceived, potential, and actual conflicts of interest and manage them to ensure services provided best meet the needs of injured people. Where there is an actual conflict, declare it to the injured person concerned, the referrer and the insurer concerned (or the Lifetime Care and Support Authority of NSW in exercising functions under the Motor Accident Injuries Act 2017)

h) comply with the applicable laws in protecting injured person’s personal and health information.

i) work collaboratively and communicate in an effective and timely manner with members of the injured person’s support team (including the insurer)about the injured person's injury, treatment, and recovery

j) participate in peer reviews of the injured person's injury, treatment, and recovery, if the RSP is a provider of allied health services

k) respond to a request from SIRA for information relating to compliance with the Act, workers compensation legislation or motor accident legislation or the regulations or guidelines made under those Acts in the form, time and manner reasonably required and requested (including consistency with privacy legislation) by SIRA from time to time.

Part 2: Requirements for telehealth services

2.1 Telehealth services means services that use videoconferencing or telephone as an alternative to an in-person consultation.

2.2 A telehealth service must be conducted by videoconference unless that medium is unavailable or determined to be inappropriate following consideration of the factors outlined in clause 2.5 below.  In those cases, telehealth services can instead be conducted by telephone.

2.3 Telehealth services must not be provided by email, SMS, or through an app. These electronic forms of communication may be used in conjunction with the delivery of telehealth services conducted by videoconference (or telephone).

2.4 Telehealth services must be provided in combination with in-person services unless the services are:

a) psychiatric treatment services, or

b) allied health mental health treatment services, or

c) services specified as being delivered exclusively by telehealth and pre-approved by the insurer managing the injured person’s claim.

These exempt services can be provided by telehealth only, provided the requirements of clause 2.5 are met.

2.5  An RSP must only provide telehealth services to an injured person that comply with the following requirements:

a) the injured person concerned requests or consents to participate in a telehealth service, and

b) the RSP determines that service provision by telehealth is appropriate for the injured person concerned following consideration of the following factors¹ :

• whether a physical assessment or treatment is required
• whether it will compromise worker outcomes
• availability of support at the injured person’s location
• availability and access to a suitable device e.g., videoconferencing units/systems or a personal device capable of videoconferencing
• ability of the injured person to participate, considering any physical, mental, social, and cognitive barriers
• ability to schedule telehealth session within the timeframes for a service
• the injured person's access to fast secure internet connection and sufficient internet or mobile data quota/allowance
• the injured person’s capability/capacity to access care this way.

Part 3: Administrative requirements for prescription of medication

3.1 The following administrative procedures apply to an RSP prescribing or dispensing medication to an injured person.

3.2 The RSP must prescribe medications through the Pharmaceutical Benefits Scheme (PBS) where clinically appropriate and available.

3.3 However, the RSP may provide a private prescription (not through the PBS) when:

a) the medication is not available on the PBS, or

b) the medication is available on the PBS, but the injured person does not meet the criteria for PBS prescribing, or

c) the quantity of medication or number of repeats being prescribed for a medication available through the PBS is outside the PBS prescribing criteria, but can be clinically justified by the prescribing practitioner; or

d) workers compensation scheme only: pre-approval has been obtained from the insurer to prescribe it privately (after the first month from the date of injury)²

3.4 If an RSP privately prescribes a high-risk medication (e.g., opioids, medication-assisted treatment of opioid dependency, injectable narcotics, benzodiazepines, Z-drugs, or medicinal cannabis) or drugs of addiction (Schedule 8³), the RSP must provide a written clinical rationale to the insurer that explains why:

a) they are prescribing a medication that is not available through the PBS; or

b) if it is available through the PBS, why they are prescribing it privately.⁴

Part 4: Requirements for provision of independent medical examination services under the workers compensation legislation

4.1 In the provision of relevant services that are independent medical examination services, but not assessment of permanent impairment services, RSPs must:

a) comply with all legal requirements for practice, including relevant policies and codes of conduct

b) comply with the Procedural Direction PIC4 – Expert Witness Evidence and any subsequent procedural directions issued by the President of the Personal Injury Commission established under the Personal Injury Commission Act 2020 relating to expert witness evidence, and the code of conduct in Schedule 7 to the Uniform Civil Procedure Rules 2005 and promptly notify SIRA of any compliance breaches

c) comply with the standards and conduct for medico-legal consultations, examinations and reports, as set out in the Medical Council of NSW’s Guideline for Medico-Legal Consultations and Examinations in effect at the time of the relevant service. Where the Guideline for Medico-Legal Consultations and Examinations refers to the Medical Board of Australia’s Good Medical Practice: A Code of Conduct for Doctors in Australia, this only applies to RSPs who are medical practitioners under the Health Practitioner Regulation National Law (NSW)

d) act without bias and in a way that does not give rise to an apprehension of bias in the performance of their responsibilities

e) act in an ethical, professional, and considerate manner when examining injured people and practise procedural fairness when conducting medical assessments and writing reports. This includes respectful communication with injured people and considering their individual needs, providing impartial assessments, and ensuring that injured people are given the opportunity to explain any inconsistencies observed during an examination or in supporting material

f) comply with all privacy obligations including under the Health Records and Information Privacy Act 2002 (NSW) and the Privacy Act 1988 (Cth)

g) not ask for or accept any inducement, gift, or hospitality from individuals or companies, or enter arrangements that could be perceived to provide inducements, that may affect, or be seen to affect, the RSP’s ability to undertake the role of providing independent medical examination services in an impartial and unbiased manner

h) not engage in activities or publicly express opinions that might be perceived to compromise the practitioner’s ability to undertake the role of providing independent medical examination services in an impartial and unbiased manner

i) have access to the necessary resources and infrastructure to do all administrative activities necessary for the role.

Part 5: Billing requirements for the provision of relevant services under the workers compensation legislation

5.1 RSPs providing relevant services under the workers compensation legislation:

a) must not request pre-payment of fees for reports and services from the insurer

b) must not directly bill relevant services to an injured worker who has already lodged a claim for the injury (excluding providers of independent medical examination services and/or providers of assessment of permanent impairment services)

c) where the maximum amount of an employer’s liability has been fixed under a SIRA fees order made under ss61 – 63A of the 1987 Act or s339 of the 1998 Act, must not:

1. bill an amount that is above the maximum amount fixed in the relevant fees order⁵
2. charge the injured person any additional or gap fee

d) must not charge a fee for cancellation or non-attendance by an injured worker for treatment services (excluding RSPs as defined in Clause 4A(1)(za) of the Regulation).

Part 6: Invoicing requirements for relevant services under the workers compensation legislation (excluding pharmaceutical services)

1. 6.1 The invoicing requirements in clause 6.2 only apply to relevant services delivered under the workers compensation legislation.

6.2 Invoices for relevant services rendered must:

a) be submitted within 30 calendar days of the service provided

b) include:

1. the injured worker’s first and last name, and claim number
2. payee name, address, telephone number and email address
3. payee Australian Business Number (ABN)
4. name of the relevant service provider who delivered the relevant service
5. 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, and
6. in the case of allied health services, the following provider numbers:
   • the provider’s SIRA approval number (where applicable), and
   • the provider’s AHPRA number/professional association accreditation/membership number
   • in the case of allied health services provided interstate by a service provider who doesn’t have a SIRA approval number, the service provider number INT0000 must be included on the invoice instead
   • in the case of allied health services provided to exempt workers, by a service provider who doesn’t have a SIRA approval number, the service provider number EXT0000 must be included on the invoice instead.
7. in the case of private hospital services, the service’s:
   • Medicare Benefits Schedule item (if applicable)
   • theatre banding (if applicable)
     • if the invoice is for a higher-banded procedure which requires a complexity certificate, the certificate of complexity must accompany the invoice.
   • theatre duration (if applicable).
8. 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.
9. relevant SIRA payment classification code or Australian Medical Association (AMA) Fees List item number (where applicable)
10. service cost for each SIRA payment classification code or AMA Fees List item number and service duration (if applicable)
11. date of service
12. date of invoice (must be on the day of or after last date of service listed on the invoice).

Part 7: Invoicing requirements for pharmaceutical services

7.1 The invoicing requirements for pharmaceutical services in clause 7.2 apply to relevant services delivered under the workers compensation legislation and motor accident legislation.

7.2 An invoice for relevant services from a registered pharmacy must include the following information:

a) pharmacy name and street address

b) dispensing pharmacist’s name

c) pharmacy ABN

d) invoice number and date

e) total amount charged

f) injured worker’s name, address and claim number (or date of birth and date of injury)

g) date of service (date dispensed)

h) PBS item code (for PBS dispensed medications)

i) a copy of the original script for medications that are available on the PBS but are dispensed privately (non-PBS), and a copy of the repeat prescription where applicable

j) full description of the medication (including script number, brand name, form)

k) quantity of medication dispensed

l) strength of the medication dispensed

m) prescriber name/address/prescriber number

n) amount charged per item.

Part 8: Application of the Guidelines by relevant service/provider

8.1 Table 1 sets out, by relevant service/provider and by scheme (workers compensation (WC) or motor accident (MA)), the application of the different Parts of the Guidelines. RSPs must comply with applicable clauses in the Guidelines.

8.2 RSPs should also note the content in the ‘About the Guidelines’ section of the Guidelines.

Table 1

Glossary

In the Guidelines:

• allied health service/s: means relevant services prescribed in clause 4A(1) (c) chiropractic, (d) counselling, (f) dietetics and nutrition), (g) exercise physiology, (l) occupational therapy, m) massage therapy, (n) osteopathy, (q) physiotherapy, (r) podiatry, (s) psychology, (u) social work, and (v) speech therapy of the Regulation.
• allied health mental health services: means services prescribed in clause 4A(1)(d) counselling, (s) psychology and (u) social work of the Regulation.
• assessment of permanent impairment services: means services prescribed in clause 4A(1)(za)(ii) of the Regulation. For the purposes of the Guidelines this applies to services provided under the workers compensation legislation only.
• culturally safe practice: means relevant services are delivered by the RSP with knowledge of how their own culture, values, attitudes, assumptions, and beliefs influence their interactions with injured people and families, the community, and colleagues⁶
• direction: means a direction given under section 26D of the Act.
• independent medical examination services: means services prescribed under clause 4A(1)(za)(i) of the Regulation. For the purposes of the Guidelines this applies to services provided under the workers compensation legislation only.
• medico-legal services: means when the RSP is providing a medico-legal service under the motor accident legislation, including in respect of the giving of evidence as set out in s 7.52 of the Motor Accident Injuries Act 2017, about the injured person related to the injury resulting from the motor accident concerned.
• motor accident legislation: for the purposes of the Guidelines means the Motor Accident Injuries Act 2017.
• overservicing: means a pattern of service provision that appears excessive when compared to the similar service provided by an RSP’s peers (being practitioners in the same profession providing the same or similar treatment for the same or similar injuries), taking into account factors such as the complexity/severity of the injuries being treated.
• peer review services: means relevant services prescribed in clause 4A(1)(za)(iii) of the Regulation.
• relevant services: means services prescribed in clause 4A of the Regulation provided in connection with a claim under the workers compensation or motor accidents legislation.
• relevant service provider (RSP): means a provider of relevant services prescribed in clause 4A of the Regulation.
• support team: a multidisciplinary team that may include the employer, insurer, doctor, allied health practitioner, rehabilitation provider and other RSPs providing treatment, care and support to the injured person.
• workers compensation legislation: for the purposes of the Guidelines means the Workers Compensation Act 1987 (1987 Act) and the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act).

References

¹Adapted from Page 20, Virtual Care in Practice, NSW Agency for Clinical Innovation

²In the workers compensation scheme, pre-approval from the insurer is not required for dispensed prescription drugs and over-the-counter pharmacy items prescribed for the injury by the nominated treating doctor or medical specialist for the first month from date of injury – see the Workers Compensation Guidelines.

³Schedule 8 of the Poisons Standard October 2022, or the Poisons Standard in effect at the time.

⁴In the workers compensation scheme, high risk medications prescribed using a private prescription within the first month from date of injury do not require a clinical rationale.

⁵SIRA WC health-related fees orders and fee and practice requirements are published on the SIRA website.

⁶Adapted from the explanations of culturally safe practice in the AHPRA & National Boards Code of conduct; the Medical Board/AHPRA Good medical practice: a code of conduct for doctors in Australia; and the Nursing and Midwifery Board/AHPRA Code of conduct for nurses.