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4.1.3 Exceptional circumstances - above rates

WorkSafe encourages all service providers to invoice the Agent directly for services provided.

Where it is not possible for service providers to invoice the Agent directly (eg prior to claim lodgement or claim acceptance) a worker may be charged which may result in a charge above the fee schedule for that service. In these circumstances there is the potential that the worker is left with an out of pocket expense.

See: Fee schedules

A provider may make an arrangement with a worker to charge an amount greater than WorkSafe’s relevant scheduled fee, resulting in an out of pocket expense for the worker. The worker is under no obligation to accept such an arrangement and may wish to seek services from another provider who does not charge more than the reasonable costs specified by WorkSafe.

Workers should speak to their Agent if they are unsure about the fee schedule prior to commencing services.

See: Information for workers

Medical services that this policy applies to

This policy applies to the list of treatments in 4.5 A-Z of medical and like services.

When WorkSafe may reimburse out of pocket expenses

WorkSafe Agents may reimburse the worker’s out of pocket expense for the above list of services where it is considered reasonable to do so if:

  • the service was provided before claim lodgement/liability acceptance or
  • the worker was genuinely unaware of the schedule of fees or
  • the worker does not have any other choice of provider due to living in a remote area or
  • the service was provided by an interstate provider (apart from interstate hospitals and interstate surgery costs) and
  • the service is for a work-related injury or illness
  • it is necessary and appropriate in the worker’s individual circumstances and
  • the principles of the Clinical Framework for the Delivery of Health Services have been adhered to.

Reimbursement for the out of pocket expenses will only apply for services provided up until the date the worker was made aware that WorkSafe Schedule of Fees applies.

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Agent’s role in these exceptional circumstances

The Agent is to clearly communicate with the worker that a schedule of fees applies to approved services following the acceptance of a claim.

For exampleClosed this may include advising what the scheduled fee is for a service a worker is seeking.

In the instance of remote workers, Agents will assist workers to identify alternate providers where possible. Agents may be required to communicate with remote providers and request providers to invoice Agents directly.

Agents may need to seek the assistance of an interpreting service (where English is not the worker’s first language) to assist workers to understand the schedule of fees.

WorkSafe will not reimburse out of pocket expenses

WorkSafe will not reimburse out of pocket expenses when:

  • the worker is aware of the schedule of fees and where the provider continues to invoice above the schedule directly to the worker
  • the worker has incurred interstate hospital/surgery costs without seeking prior approval
  • prior approval is required (including services sought overseas etc)

If surgery took place interstate before claims lodgement/liability acceptance, the worker should discuss the reimbursement of any out of pocket expenses with the Agent. The Agent may reimburse these out of pocket expenses in exceptional circumstances.

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