4.5.25 Medical practitioner services
Workers are entitled to be compensated for the reasonable cost of medical and like services incurred as a direct result of a work related injury or illness under the legislation. The legislation describes how WorkSafe determines the type of services it accepts as compensable. This section outlines the requirements of the legislation and WorkSafe’s policy regarding reimbursement for services provided by medical practitioners.
WorkSafe can pay for the reasonable costs of a medical and like expense where a worker is entitled to provisional payments on a claimed mental injury.
See: 6.5 Provisional payments for a mental injury
Service definition
The legislation includes in the definition of a ‘medical service’, attendance, examination or treatment of any kind by a registered medical practitioner.
Policy
See: Policy for Medical Practitioners
The policy includes:
- what can be paid for
- referral requirements for allied health and other services
- surgical procedures
- disclosure of medical information
- GP RTW Return to Work activities
- magnetic resonance imaging.
Fee schedule
WorkSafe publish a fee schedule for Medical Services.
See: Reimbursement Rates for Medical Services | Medical Services – Medicare Benefits Schedule | General Practitioner Return to Work Activities
Reasonable costs
WorkSafe is only liable to pay the reasonable costs of the services if the provider is a registered medical practitioner within the meaning of the Health Practitioner Regulation National Law Act 2009.
Medical practitioners practicing in States and Territories outside Victoria must be lawfully qualified in that State or Territory for the service to be recognised.
Medical practitioners outside Australia must be lawfully qualified in that place to do that thing and must be approved by WorkSafe or self-insurer.
Any enquiries should be directed to the Provider Registration Unit of WorkSafe.
Choice of provider
Medical services can be provided by any registered medical practitioner of the worker’s choice. To ensure that the medical practitioner meets the requirements in the legislation for providing medical services to workers, the practitioner should contact WorkSafe's Registrations Branch.
What the worker needs to provide to the provider/Agent
For WorkSafe to pay for medical practitioner services the worker must be able to show that the service item is:
- required because of the injury that has entitled him/her to compensation
- provided by a registered medical practitioner.
Medical certificates
The first certificate of capacity Ongoing certificate is issued for up to 28 days and can be issued by a: medical practitioner, osteopath, physiotherapist, chiropractor. must be completed by a medical practitioner. Subsequent certificates may be issued by a registered chiropractor, registered physiotherapist Registered physiotherapist means a person registered under the Health Practitioner Regulation National Law to practise in the physiotherapy profession (other than as a student). and registered osteopath.
The certificate of capacity is available from WorkSafe website as a PDF SmartForm or Word document. Printed forms are available through Print Media Group via email: custserv@pmg.com.au or fax (03) 8761 4981.
Medical information about the worker
A claim for compensation must include an authority signed by the worker authorising a provider of a medical service or hospital service in connection with the injury to give WorkSafe, employer or Conciliation Officer information about the service relevant to the claim.
This authorisation cannot be withdrawn and is therefore valid for the duration of the claim. A legible copy of the Claim form is therefore sufficient documentation to provide to a medical practitioner when requesting health information to these parties.
Can a medical practitioner refer for allied health services
WorkSafe only accepts payment of the reasonable costs for services provided by certain allied health providers if there is a written request/referral from a medical practitioner.
A medical practitioner referral is not required for physiotherapist, chiropractor, osteopath, podiatrist Registered podiatrist means a person who is registered under the Health Practitioner Regulation National Law to practise in the podiatry profession (other than as a student)., optometrist, hearing aid provider or occupational rehabilitation provider services.
Details required on an invoice
WorkSafe reimbursement rates are not payable in respect of professional services provided unless the following particulars are recorded on the service provider’s invoice:
- invoice number and/or the date of the invoice
- worker’s name, claim number and date of injury (date of birth may be included if claim number is unknown)
- employer’s name
- service provider’s number, who actually performed the service and/or the provider number for that location
- practice address details, indicating site at which the service was rendered
- date(s) of service on which the professional service was rendered
- MBS Medicare Benefits Schedule item numbers used to describe the professional service or treatment provided
Note: Some practitioners may use AMA American Medical Association equivalent item numbers.
- description of the service sufficient to identify the MBS items numbers
- fee charged for each medical service.
- Specialists and consultant physicians should also include:
- name of the referring medical practitioner
- the referring practitioner’s place of practice or provider number.
Accounts from overseas providers
The Agent must have accepted liability for services provided whilst the worker is outside Australia. When accounts are received the normal checks or vetting that is required before any account can be paid must also be carried out on accounts for services rendered overseas.
Special attention must be paid to the information provided on the account. If the name, address, qualifications and type of service provided are not clearly legible the account should be returned to the worker or the service provider.
Copies of accounts, translated into English if required, should be forwarded to the Registrations Branch of WorkSafe. A service provider registration/amendment form must be included.
MBS rules
Agents are advised to access the MBS book, either as hard copy available from Government bookshops or freecall on 1800 020 103 or from the Department of Health and Ageing website.
Explanatory notes relating to the Medicare Benefit arrangements and notes that have general application to services are located at the beginning of the MBS book, while notes relating to specific service items are located at the beginning of each category.