4.1 Cost of Services
4.1.1 Costs WorkSafe pays | 4.1.2 Reasonable costs | 4.1.3 Exceptional circumstances - above rates | 4.1.4 THP reports
Workers are entitled to be compensated for reasonable costs of medical and like services incurred as a result of a work-related An injury/disease is work related if it arose out of or in the course of employment and the scope of employment. injury or illness.
Workers can also have reasonable medical and like costs covered if they are entitled to provisional payments for a claimed mental injury. If a worker is entitled, the reasonable costs of medical treatment and services relating to the claimed mental injury can be paid:
- while the claim is pending, while the Agent determines whether the claim will be accepted or rejected
- in the case of a claim rejection, up to 13 weeks after the day the worker is determined under section 75A to be entitled to provisional payments.
Reasonable costs
Reasonable cost is the amount determined by WorkSafe as reasonable in relation to a service. WorkSafe can pay for medical and like services up to the maximum amount detailed in the relevant fee schedule.
WorkSafe is only liable to pay the reasonable costs of the services if the provider has met the WorkSafe provider registration requirements.
See: A-Z of medical and like services
4.1.1 Costs WorkSafe pays
In determining what will and will not be paid for, principles of good administrative decision making must be applied. WorkSafe will only pay the reasonable cost of a service or treatment, in line with the fee schedule.
See: Decision making process | Principles of good administrative decision making
WorkSafe can pay for
WorkSafe can pay for the reasonable costs of a medical and like expense where:
- the service, treatment or item is for a work-related injury or illness
- a worker is entitled to provisional payments on a claimed mental injury, and the treatment is because of the claimed mental injury. Provisional payments can be made until either the claim is accepted or if the claim is rejected, for 13 weeks after the day the worker is determined under section 75A of the WIRC Act Workplace Injury Rehabilitation & Compensation Act 2013 to be entitled to provisional payments.
See:6.5 Provisional payments for a mental injury - the service is reasonable, necessary and appropriate in the worker’s individual circumstances
- the particular service meets WorkSafe criteria/guidelines and is approved by WorkSafe
- the service provider is currently registered with WorkSafe to deliver the service being provided
- prior approval has been given by the Agent, where required
- invoices have been provided to the Agent in the case of worker seeking reimbursement
- other policy specific requirements (e.g. where referrals are required for services/items) have been satisfied and
- the principles of the Clinical Framework for the Delivery of Health Services to workers are adhered to.
Note: Agents do not have the delegation to approve services or service providers
Please note that WorkSafe's preference is for workers to attend THP appointments outside of their working hours, where possible.
See: Reasonable cost | A-Z of Medical and Like services | Workers attending THPs
WorkSafe will NOT pay for
- treatment or services provided outside Australia, unless the Agent has provided prior approval
- appointments where a worker cancels or does not attend (except for independent medical examination appointments)
- future medical and like services (e.g. where appointments are scheduled ahead of time and billed in advance)
- telephone consultations or conversations outside of the Telehealth Policy (e.g. between the worker, the employer, WorkSafe, Agents, self-insurers or other healthcare professionals).An exception is GP phone calls to employers relating to a worker’s return to work – see: General Practitioner Return to Work (RTW) Activities
- more than one service of the same type provided on the same day (except for GP services where worker has seen GP, then another provider e.g. for an x-ray, then come back to GP to interpret the results)
- services provided by healthcare professionals to their immediate family members Family member means a partner, parent, grandparent, sibling or child of the worker or of the worker's partner.
4.1.2 Reasonable costs
Every service must be considered on its individual circumstances and merits. The Agent must consider all available information to determine if the service is necessary and appropriate in light of the specific requirements of a particular policy.
This information should be referred to in assessing liability where appropriate.
See: A-Z of medical & like services
Information to consider
Reports from:
- treating health practitioners (especially those in a relevant discipline to the request who are primarily responsible for identifying what medical and like services the worker requires)
- Independent Medical Examiners
Recommendations from:
- Medical Advisors
- Clinical Panel (a clinician from a relevant discipline)
Information in forms/documents:
- Certificates of Capacity
- return to work plans/arrangements
- treatment notification forms
- treatment review forms
- treatment reports or any other relevant past treatment information
Any other relevant information:
- in Novus and ACCtion eg previous decisions about approving or rejecting a particular item
Note: prior service authorisation does not in itself set a precedent for future service. - additional information received eg following a request for additional information
Any additional information specific to particular policies is referred to under the relevant policy.
Liability should be assessed/determined by suitably qualified or authorised person.
