Regulation of health and related services providers

The State Insurance and Care Governance Act 2015 (SICG Act) and the State Insurance and Care Governance Regulation 2021 (the Regulation) empower SIRA to regulate health and related service providers (RSPs) who don’t comply with relevant legislation and guidelines. The Guidelines for the Provision of Relevant Services (Health and Related Services) (the Guidelines) outline SIRA’s service and billing expectations for health and related providers in the WC and CTP schemes.

SIRA's Supervision of Relevant Service Providers: Information for Providers explains in more detail how regulation of RSPs will work.

Who is a relevant service provider?

A relevant service provider is a person, organisation or body who provides a ‘relevant service’, as listed in Clause 4A of the Regulation, such as:

• medical practitioners
• allied health practitioners
• workplace rehabilitation providers
• medico-legal providers
• injury management consultants and independent consultants
• pharmaceutical services
• dentists
• providers of domestic assistance
• providers of aids, appliances or prostheses
• certain health-related administrative services.

Read the full list of relevant service providers here.

Regulatory powers

The State Insurance and Care Governance Act 2015 (SICG Act)

The SICG Act gives SIRA the power to (amongst other things):

• direct relevant service providers to provide information/data (section 26C direction)
• direct relevant service providers to take specified action or provide/not provide specified relevant services (section 26D direction)
• keep a register of providers given a 26D direction
• make regulations and issue guidelines

The Regulation

Clause 4A  of the Regulation lists which services are considered relevant services.

Under the Regulation, SIRA may issue a direction to a relevant service provider who:

• does not comply with a provision of the workers compensation and motor accidents legislation, or guidelines issued under section 26E of the SICG Act, or the workers compensation and motor accidents legislation
• has been referred to, or is under investigation, by a relevant clinical, professional or accreditation body.

The Guidelines

The Guidelines for the Provision of Relevant Services (Health and Related Services) (the Guidelines) specify SIRA’s service and billing expectations for RSPs including:

• a code of conduct for providers in CTP and WC (except for those who already are, under a separate SIRA approval framework)
• requirements for telehealth services to ensure the needs of the injured person are met
• requirements for independent medical examiners in the WC scheme (consistent with the CTP scheme’s)
• invoicing and billing requirements
• administrative requirements for the prescriptions of medication.

Not all parts of the Guidelines apply to all relevant service providers in the WC and CTP schemes – see Part 8 of the Guidelines for a guide to which parts apply to who.

Failure to comply with the Guidelines may result in a direction being given under the SICG Act (see above). Failure to comply with a direction may result in penalties.

What types of behaviour will SIRA regulate?

SIRA will regulate behaviours that don’t comply with the Guidelines and/or the workers compensation and motor accidents legislation, regulations, and guidelines. Some examples of matters that SIRA may investigate include:

• reports that don’t comply with requirements in guidelines
• services delivered without required pre-approval
• billing for amounts that are more than the maximum fee fixed by SIRA
• billing for items the RSP is not eligible to bill for - e.g., billing for a medical specialist item when they are not a medical specialist
• servicing patterns which vary significantly from the RSP’s peers, considering factors such as the complexity/severity of injuries being treated.

SIRA's regulatory activity will in general be most focussed on relevant service providers with a pattern of non-compliance rather than one-offs.

What types of RSP behaviour will SIRA not regulate?

In general, SIRA will not investigate concerns about a RSP’s clinical or professional conduct or intervene in individual clinical decision-making.

If clinical concerns arise, and SIRA considers there is a potential risk to an injured person’s health or welfare, SIRA may choose to refer the matter to an appropriate body with the expertise to investigate, such as the Health Care Complaints Commission, the Health Professional Councils Authority, or other relevant body.

What will SIRA do in response to non-compliance?

SIRA’s response to non-compliance will consider a range of factors, to ensure actions taken are appropriate, proportionate, and effective.

Providers will be given the opportunity to make submissions about their behaviour and why further compliance activity is not warranted.

Read SIRA's Supervision of Relevant Service Providers: Information for Providers for more information.

What is the register?

Publication of the register of providers given directions will help scheme participants make informed decisions about an RSP. The register will include the following about providers who have been given a direction under s26D of the Act:

• the RSP’s name
• the RSP’s ABN and/or Australian Health Practitioner Regulation Agency registration number, or professional association registration number, as applicable
• the RSP’s SIRA provider number (if applicable)
• the relevant services provided by the RSP
• information relating to the direction given to the RSP, including:
  • the direction given, and
  • the date the direction came into effect and any expiry date.

SIRA may decide whether it is appropriate or not to publish the above information in individual cases.

Register of directed service providers

The Register of Directed Services Providers Policy (the Policy) explains SIRA’s approach to publishing and updating information on the register. The Policy provides information on:

• the circumstances that will lead to publication on the register
• the information included on the register
• procedural fairness
• the issues SIRA may consider when deciding what information is published on the register
• when the register can be corrected and updated
• who else may be notified about a direction
• SIRA’s obligations under the NSW privacy legislation.

More information

• SIRA's Supervision of Relevant Service Providers: Information for Providers
• For more information about the Act, Regulation, or Guidelines email SIRA
• View the outcomes of the public consultation on Regulation and Guidelines:
  • Regulation consultation outcomes
  • Guidelines consultation outcomes