2.8.4 Potential scheme abuse and non-compliance
2.8.4.1 Identifying potential scheme abuse | 2.8.4.2 Reporting allegations of suspected offence or non-compliance | 2.8.4.3 Termination of benefits for fraud | 2.8.4.4 Recovery of payments | 2.8.4.5 Impact of fraud on premiums
Agents are responsible for notifying the Agent Enforcement SME of suspected scheme abuse or non-compliance with the legislation.
The Agent Enforcement SME is responsible for referring suspected scheme abuse or non-compliance to WorkSafe's Compensation Investigations.
Compensation Investigations monitor and investigates offences and breaches of the legislation by all scheme stakeholders including workers, employers and service providers.
A potential offence is identified by one of the following three main sources:
- Agents - through claim alert indicators and information gained in the management of claims.
- Compensation Investigations - through trend and data analysis and reviewing individual claims.
- allegations obtained from any other source, including injured workers, employers, and the general public.
For a comprehensive list of offences, see: Offences under the Victorian workers compensation legislation.
2.8.4.1 Identifying potential scheme abuse
Agents are required to check claims for potential scheme abuse at specific times through the life of the claim.
2.8.4.2 Reporting allegations of suspected offence or non-compliance
Agent referral to Agent Enforcement SME
When the Agent identifies suspected offences or non-compliance, the details which establish the suspicion must be reported to the Agent Enforcement SME. The Agent Enforcement SME will review the matter in consideration of a referral to WorkSafe’s Compensation Investigations.
Reasonable evidence of a suspected offence
Allegations received by Agents of suspected offences or non-compliance must be promptly reported to the Agent Enforcement SME for consideration of referral to Compensation Investigations. Compensation Investigations will advise the Agent Enforcement SME as to the appropriate actions. In undertaking those actions Agents must ensure that they do not hinder any possible future investigation.
If an Agent suspects a worker has engaged in undeclared employment:
- the Agent should consider a period of surveillance to determine whether there is any foundation to the allegation, see: Allocate investigations.
Note: The Private Investigator must be instructed not to approach the worker or employer.
If an Agent suspects that an employer is failing to make weekly compensation payments in accordance with the legislation they should:
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contact the worker and employer to ascertain if there is a genuine reason for non-payment. Detailed file notes should be made by the Agent.
Compensation Investigation provides advice
If there are any doubts as to what action is required, advice should be sought from Compensation Investigations by the Enforcement SME.
Reasonable evidence of a suspected offence
When the Agent believes that a possible offence exists, the details regarding the circumstances which establish the suspicion of an offence are referred by the Agent Enforcement SME to Compensation Investigations.
A referral to Compensation Investigations is made via email to compensation_investigations@worksafe.vic.gov.au.
If Agents receive direct evidence of scheme abuse or non-compliance (e.g. through a surveillance report), the Agent Enforcement SME must refer the matter to WorkSafe’s Compensation Investigations, ensuring all relevant documentation is included.
Compensation Investigations assesses the allegation and liaises with the Agent Enforcement SME about the future management of the claim.
The Agent is still responsible for managing the claim. However, ongoing consultation with Compensation Investigations is crucial.
If WorkSafe determines that an offence has been committed it may take prosecution action against the offender and seek recovery of monies obtained fraudulently.
Penalty units
Various sections of the legislation include penalties for offences for non-compliance. These penalties are specified as a number of penalty units.
The value of a penalty unit for a financial year is fixed by the Treasurer under the Monetary Units Act 2004 and published in the Government Gazette.
| Year | Value of penalty unit |
|---|---|
| 2023/24 | $192.31 |
| 2022/23 | $184.92 |
| 2021/22 | $181.74 |
| 2020/21 | $165.22 |
| 2019/20 | $165.22 |
| 2018/19 | $161.19 |
| 2017/18 | $158.57 |
| 2016/17 | $155.46 |
| 2015/16 | $151.67 |
| 2014/15 | $147.61 |
| 2013/14 | $144.36 |
| 2012/13 | $140.84 |
| 2011/12 | $122.14 |
2.8.4.3 Termination of benefits for fraud
Agents can only terminate weekly payments and professional services on fraud grounds by the worker if they have authorisation from Compensation Investigations at WorkSafe. The Agent must only include information provided by Compensation Investigations in the termination notice to the worker.
See: Terminating weekly payments
WorkSafe’s Compensation Investigations will advise the Agent Enforcement SME in writing of any decisions to terminate for fraud.
2.8.4.4 Recovery of payments
If a person is convicted of an offence for fraud or for providing false or misleading information, payments made as a result of the offence may be recovered from the person, together with an additional sum equal to half the amount of the payments made, together with interest at the prescribed rate Interest at the prescribed rate means interest at the rate fixed for the time being under section 2 of the Penalty Interest Rates Act 1983.
When a prosecution is successful, the Court would normally order that the offender make restitution. Monies recovered by the Courts are forwarded to WorkSafe.
2.8.4.5 Impact of fraud on premiums
Under the WorkCover Premiums Order, effective from 1 July 2026, certain claim costs attributable to fraudulent conduct may be excluded from an employer's claims costs for premium calculation purposes.
This provision applies to fraud terminations occurring on or after 1 July 2026 and is not applied retrospectively to matters finalised prior to the commencement of the Premiums Order changes.
Where weekly compensation payments have been terminated on fraud grounds, WorkSafe may consider whether claim costs associated with the period of fraudulent conduct should be excluded from the employer's claims experience in accordance with the Premiums Order.
Scheme Integrity will assess fraud matters and identify those suitable for premium review consideration. Eligible matters may be referred to WorkSafe's Premium Review Team by Scheme Integrity following implementation of the fraud termination and cessation of compensation payments.
The amount referred for premium review will be determined using claim payment information relevant to the established fraud period and may include weekly compensation, superannuation and other applicable claim costs.
Matters proceeding to a criminal investigation may be referred for premium review following the finalisation of prosecution proceedings or an alternative enforcement outcome.
Where a matter is referred to WorkSafe's Premium Review Team, the matter will be assessed in accordance with the Premiums Order and the broader premium framework to determine whether a premium adjustment is applicable.
Where premium relief is identified, WorkSafe will calculate the applicable adjustment and advise the relevant WorkSafe Agent for communication to the employer.
Where future premium periods may be impacted and the relevant Premiums Order has not yet been gazetted, the matter may be retained for consideration once the applicable Premiums Order comes into effect.
It is important to note that a fraud termination, or a referral to the WorkSafe Premium Review Team for consideration, does not automatically result in a premium adjustment being applied.
Any premium adjustment will depend on the individual circumstances of the claim and the application of the broader premium framework, including the treatment and timing of the relevant claim costs within the premium calculation.