4.3.2 Receive account or receipt
The Agent can receive an account or receipt in the following ways:
- employer sends invoice
- service provider sends invoice
- worker sends receipt and invoice
- Medicare or private health fund requests reimbursement.
See: Determine what is reasonable & necessary
Employer sends invoice
Agents can receive an invoice from the worker’s employer. The worker will receive a service and the service provider will forward the invoice to the employer (unless the worker is entitled to provisional payments or unless alternative arrangements have been made to forward the invoice directly to the Agent).
The Agent must ensure the employer has paid their initial liability (excess) for medical and like services unless the employer has taken a ‘buy-out’ option or unless the worker is entitled to provisional payments.
Service provider sends invoice
Some service providers may wish to make arrangements to bill Agents directly, to facilitate prompt payments of invoices.
If an Agent has such an arrangement in place with a provider, when they receive an invoice they must firstly check that the employer has paid their initial liability of medical and like services.
Worker sends receipt
If the worker has already paid an invoice, they can send the original invoice plus the receipt to the Agent for reimbursement.
The Agent must only reimburse the worker for reasonable costs of the expense.
Health insurance fund or Medicare sends reimbursement request.
The Agent must reimburse health insurance funds or Medicare where the claimed service was reasonable and necessary for the 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, or for the treatment of the claimed mental injury where the worker is entitled to provisional payments, in line with WorkSafe's fee schedules.
There may be out of pocket expenses that the Agent cannot pay when a worker has had treatment without prior approval.
Health insurance fund
The health insurance fund provides a record of services paid, which is enough evidence for reimbursement to be made to the fund.
The worker can request reimbursement for the difference between the reasonable costs and what was paid by the health insurance fund. In this case, the Agent refunds the shortfall to the worker.
4.3.3 Determine what is reasonable & necessary
Medical and like services can be undertaken when:
- prior approval is sought by the worker or provider or
- an account for the service or reimbursement request is received by the Agent.
Reasonable treatment
The Agent decides if the treatment is reasonable. Consider:
- whether the service has been approved by WorkSafe and the service provider is registered appropriately
- the number or frequency of services – this is to be monitored by the Agent
- the necessity of the service to treat the compensable injury or the claimed mental injury where the worker is entitled to provisional payments
- the benefit to the worker of the treatment, which depends on the nature and severity of the injury
- whether the cost of the service is reasonable.
Consider available information
The Agent should consider all available information when assessing the necessity of a service. This can include:
- reports from treating doctors
- Certificates of Capacity
- medical reports from independent medical examiners.
Seek further information
If there is any doubt about the necessity of a service, the Agent may even seek further information. The Agent can request:
- progress reports from the treating medical practitioner or healthcare professional
- that an independent medical examination occurs before determining if the proposed medical and like service being provided is necessary – when prior approval is being sought.