Medical and related services

Overview

Doctors and other medical professionals play an important role in a worker’s return to health and work following injury. They are likely to have a close relationship with the worker and have the capacity to positively influence return to work outcomes through expectation setting, certification and healthcare management.

Nominated treating doctors and specialists support the worker’s recovery by:

• educating them on their injury and recovery options
• where appropriate, recommending treatment to help in their recovery
• acting as the primary contact for treatment and recovery information for employers, insurers and other parties involved in the management of the injury
• applying the principles of the clinical framework for the delivery of health services.

This guidance assists insurers to effectively engage with a worker’s nominated treating doctor and/or specialist.

Nominated treating doctor

The nominated treating doctor’s role involves assessing, diagnosing, treating and certifying workers, as well as:

• supporting the worker’s recovery at/return to work, through appropriate clinical intervention and management
• contributing to recovery at/return to work planning in collaboration with the worker and the insurer, employer, workplace rehabilitation provider and other treatment practitioners.

Certificates of capacity (see also Insurer guidance GN 3.3 Certificate of capacity) issued by the nominated treating doctor must be dated on the day of examination. However, a doctor may certify that a period of incapacity occurred prior to the date of examination.

Treating medical specialists

Treating medical specialists are medical practitioners recognised as a specialist by the Australian Health Practitioner Regulation Agency (AHPRA) and remunerated at specialist rates under Medicare.

Treating specialists may be involved in the management of a worker’s injury and can assist the nominated treating doctor, facilitate recovery and provide information that will help with completing the certificate of capacity.

Communication with the nominated treating doctor and treating specialists

The nominated treating doctor is often the first point of contact for a person who has suffered a work-related injury. They can also be engaged to recommend and/or facilitate other reasonably necessary treatment and services.

The insurer is the primary contact for the worker and other key stakeholders supporting the worker to recover at/return to work. They should make early contact with the worker and employer and the nominated treating doctor (if appropriate and reasonably practicable) to determine any assistance the worker requires and establish preferred times and methods of communication.

It is important to consider language used when engaging with nominated treating doctors and specialists. Insurers should:

• use plain English and avoid jargon
• provide a clear explanation as to why the doctor and/or specialist is being contacted
• tailor their questions to the case
• if a case conference has been organised, inform the doctor and/or specialist of the topics to be discussed
• ensure that duplicate information is not being provided to the doctor and/or specialist.

Clear communication and collaboration are essential to:

• understanding the worker’s capacity and needs
• identifying any barriers or risks to recovery
• the development of effective strategies to address these issues
• the development of shared goals and recovery expectations
• ensuring the worker receives consistent messaging from all involved, and
• ensuring the right services are provided at the right time.

Working toward best practice

The insurer, nominated treating doctor and/or specialist have a shared interest in achieving an optimal outcome for the worker. It is important to try and establish a good working relationship. This can be achieved through respectful and targeted communication (both written and verbal).

Insurers can:

• contact the doctor and/or specialist early, especially if the worker is at risk of delayed recovery
• be mindful of the doctor and/or specialist’s busy schedule, and find out how and when they prefer to communicate (by phone or email, or during certain hours or days)
• schedule time to talk with the doctor and/or specialist about the worker's injury and claim, and give them a brief list of questions beforehand
• give the doctor and/or specialist the case manager’s full name and direct contact number
• respect agreed timeframes or commitments made with the doctor and/or specialist, including responding to requests in a timely manner
• ensure telephone and email contact is personalised and relevant to the worker
• forward relevant information to the doctor and/or specialist (such as workplace assessments, position descriptions, medico-legal reports) in a timely manner
• ensure prompt payment of invoices
• ensure requests for information are valid, have not been previously provided, and are relevant to the work-related injury.

Provisional liability for medical expenses

Insurers may make payments for medical expenses on a provisional basis, without admitting liability, so that a worker is not disadvantaged by delays while waiting for a claim to be determined (see section 280 of the Workplace Injury Management and Workers Compensation Act 1998). Provisional liability for medical expenses up to $10,000 can be paid before making a formal determination of liability (see Part 2.2 of the Workers compensation guidelines).

A worker who has suffered a compensable injury may also be entitled to compensation for medical, hospital and rehabilitation expenses and domestic assistance. See Insurer guidance GN 6.1 Determining liability for medical or related treatment for more information on this.

Fees and invoicing

The insurer is responsible for authorising and paying reasonably necessary medical and related expenses. Treatment expenses are subject to regulation regarding maximum costs or fees that may be charged by medical practitioners and other service providers.

Fees for medical practitioners are set out in the Medical Practitioner Fees Order.

The Fees Order (including any reference to the Australian Medical Association’s List of Medical Services and Fees) specifies:

• the maximum amount payable for medical treatments and services carried out for workers compensation claims
• the codes nominated treating doctors are to use when invoicing
• other provisions/rules relating to invoicing for surgery
• what various services include
• that workers are not liable for these costs.

Fees for Surgeons and Orthopaedic Surgeons are set out in the Surgeon Fees Order and Orthopaedic Surgeon Fees Order respectively.

Treating medical specialists and consulting surgeons

For treating medical specialists and consulting surgeons, the initial specialist consultation fee includes the first consultation, the report to the referring general practitioner and a copy of the report to the insurer. The report will contain:

• the worker’s diagnosis and present condition
• an outline of the mechanism of injury
• the worker’s capacity for work
• the need for treatment or additional rehabilitation, and
• medical co-morbidities that are likely to impact on the management of the worker’s condition (subject to relevant privacy considerations).

Charging for treatment discussions

Nominated treating doctors and/or specialists can invoice for discussions with insurers and/or employers, when the conversation relates to the worker’s capacity for work, barriers to their return to work, and strategies to overcome these barriers. The Medical Practitioners Fees Order provides the relevant fees payable.

Discussions between treating medical practitioners and other treating practitioners (for example, allied health practitioners, medical specialists and surgeons) relating to the worker’s treatment are considered a normal interaction between treating practitioners and cannot be charged.

If the nominated treating doctor or specialist has been requested to provide an opinion in relation to a dispute (or potential dispute) regarding a claim made by the worker, the report fee is invoiced in accordance with gazetted fees listed in the Medical Examinations and Reports Fees Order.

Invoices

Section 60 of the Workers Compensation Act 1987 (1987 Act) makes provisions in respect to claims for medical expenses. Insurers are to verify maximum amounts prescribed and make payment of costs incurred after production of a valid receipt or tax invoice.

Invoices must meet SIRA invoicing requirements (refer to Standard of practice 10: Payment of invoices and reimbursements) and should be submitted to the insurer within 30 calendar days of the treatment.

Insurers are to pay provider invoices promptly. Prompt payment is considered to be within ten working days of receipt of the invoice or the provider’s specified business terms, whichever is later. It is preferable that payments to providers are made by Electronic Funds Transfer (EFT).

An insurer will not be liable to pay for any medical treatment or services, or related travel, where:

• the insurer has not given prior approval for the treatment or service (subject to exemptions listed in the Workers compensation guidelines)
• the person administering the treatment is not appropriately qualified
• the treatment or related service is not reasonably necessary
• the treatment is not in accordance with any conditions imposed by the Workers compensation guidelines
• the person administering the treatment is subject to a disciplinary process, or to restrictions on practice, under any relevant law.

Working toward best practice

Insurers should call the nominated treating doctor or specialist if they have questions regarding an invoice. Errors or queries can often be resolved quickly over the phone, and this is beneficial to all parties. If telephone contact is unsuccessful, then an email or letter should be sent seeking clarification.

Insurers should always attempt to resolve an issue rather than just not pay an invoice. Non-payment of an invoice can be detrimental to the insurer-health practitioner relationship, and may negatively impact the worker’s recovery.