5.5.9 Audits - Occupational Rehabilitation Provider Incentives

WorkSafe has in place an Auditing Framework of incentives (and other item codes) paid to Occupational Rehabilitation (OR Occupational Rehabilitation) providers.

The framework exists to maintain high levels of data integrity in the oversight of performance of OR providers and to accurately reflect outcomes achieved by OR providers.

Audit streams

There are two key audit streams:

  1. Original Employer Services Incentive (OES Original Employer Services) Audits

  2. New Employer Services Incentive (OES) Audits

Both audits identify incentives that may have not met the billing practices as outlined in the OR Fee Schedule

OES and NES incentives audit process

The following process applies with respect to OES and NES New Employer Services incentive audits:

Step Action
Receive incentive exceptions

Within the first 5 business days of each month, WorkSafe provides each Agent OR SME incentive exceptions for their review
Review

The Agent OR SME must review the data from WorkSafe within 4 weeks paying particular attention to the “reason” as identified in the reporting for the incentive being flagged

Note: the Agent OR SME review should include Novus / ACCtion claim and payment records

Outcome

Incentive is payable:

  • Agent OR SME updates comments against the line item in the data from Worksafe, NFA

Incentive is not payable:

Within the 4 week review period, the Agent OR SME should:

  • write to the OR provider to notify them that an incentive they have billed may not be payable and;

  • within the 4 week review period, the Agent OR SME and the OR provider should come to an agreement as to whether the incentive is or is not payable

  • update comments against the line item in the data from Worksafe, to show:
  • evidence that recoveries have been request from the OR provider or;
  • evidence that recoveries have been received from the OR provider
Return review comments Agents should return the data from WorkSafe with commentary by the end of the 4 week period
Reconcile

WorkSafe reconciles line items where an incentive is not payable.

Incentive is not payable

WorkSafe writes to OR provider to confirm that the incentive:

  • has been identified as ineligible following an Agent review and;

  • is being nullified against that providers performance, and will occur before the incentive is nullified

Nullify incentive

WorkSafe to nullify incentive from OR performance data

Following confirmation from all parties that the incentive/s are not payable; WorkSafe will request the incentive/s are nullified from data

 

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