Elective surgery services policy

What WorkSafe will pay for

A WorkSafe agent can pay the reasonable costs of elective surgery when required as a result of a work-related injury or illness. This service must be provided by a registered medical practitioner in accordance with Victorian workers compensation legislation.

WorkSafe uses the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions for surgical services. Services must be provided by suitably qualified medical practitioners.

This policy must be read in conjunction with the following documents:

Definitions

What is elective surgery?

Elective surgery is a clinically necessary, non-emergency surgical treatment (including surgical procedures) performed by a registered medical practitioner.

Guidelines

What elective surgery costs can the agent cover?

An agent can pay the reasonable costs of surgical services that:

• have an item number in the MBS
• are clinically justified
• are required as a result of a work-related injury or illness
• are requested and performed by a registered medical practitioner

An agent can also pay the reasonable costs of:

• hospital and theatre fees in accordance with the relevant and current WorkSafe private hospital fee schedule
• surgically implanted prosthetic items as listed on the current prescribed list of medical devices and human tissue products published by the Australian Government Department of Health and Aged Care and in accordance with the surgically implanted prostheses policy

Information an agent requires to consider paying for elective surgery

An agent must provide written approval before elective surgery can be performed.

To make a timely decision on a request and to ensure the most appropriate services are provided, agents require a written request from a medical practitioner that includes:

• the name and claim number of the patient
• the name of the medical practitioner performing the elective surgery
• current diagnosis of the work-related injury or illness
• a full description of the elective surgery requested
• the clinical rationale and justification for the surgery and the relationship between the surgery and the work-related injury or illness
• the anticipated hospital admission requirements associated with the surgery
• the MBS item number(s) associated with the specific elective surgery request
• the anticipated prosthesis details, if required. If this is a gap-permitted or unlisted prosthesis, written clinical justification is required - refer to WorkSafe's surgically implanted prostheses policy
• the outcomes of previous treatments
• information about consideration of alternative treatment options
• the expected outcomes of proposed surgery, including post-surgery treatment and rehabilitation needs
• reference and access to the relevant imaging reports to support the clinical rationale and justification for the request

An agent can accept this information in a letter from a surgeon to a third party, for example, the referring GP. This should be provided with notification from the surgeon clearly starting that this is a request for funding.

When will I receive a response?

Requests for surgery are assessed as high priority. The majority of surgery requests will have an outcome within 28 days.

There are four possible outcomes from a surgery request review:

• more information is required to make a decision (for example information from the treating health practitioner, the surgeon, an independent medical examiner or other medical consultant)
• an independent medical practitioner opinion may be sought
• the proposed surgery may be approved
• the proposed surgery may not be approved

Due to the nature and complexity of some elective surgery requests an agent may require information from more than one source. This may add to the time it takes for an agent to make a decision.

What invoicing information is required from medical practitioners?

It is a WorkSafe requirement that each item billed must be supported by adequate detail in the hospital operation report.

For further details please refer to How to invoice WorkSafe.

What fees are payable for elective surgery?

An agent can pay the reasonable costs of elective surgery in accordance with the:

• reimbursement rates for medical services
• private hospital fee schedules
• Victorian Department of Health's fees manual
• minimum price of surgically implanted prosthetic items as listed on the prescribed list of medical devices and human tissue products

What will the agent not pay for in relation to elective surgery?

An agent will not pay for:

• services that are not in accordance with the MBS items, explanations, definitions, rules and conditions for services provided by medical practitioners, unless otherwise specified by WorkSafe
• the provision of hospital operation reports as these reports form part of the surgical service and are generated at the time of the surgical procedure
• the medical practitioner to provide additional information to the agent which had previously been requested by the agent but not supplied
• services for a condition that existed before the work-related injury or illness or that is not a direct result of the work-related injury or illness
• treatment or services where there is little or no scientifically strong evidence that the treatment or service is safe and effective. Refer to the non-established, new or emerging treatments and services policy

• services that are of no clear benefit to the worker
• non-attendance fees where a worker failed to attend
• the cost of telephone calls and telephone consultations between providers and patients, and between other providers, including hospitals that falls outside the approved telehealth/virtual health MBS item codes found within WorkSafe's Medical Services – Reimbursement rates fee schedule
• treatment or services provided by telephone or other non face to face mediums that do not align with WorkSafe's telehealth policy
• treatments and/or services subcontracted to a non-registered provider
• services provided outside of Australia without prior approval from the agent
• treatment provided to members of the immediate family of the registered medical practitioner
• invoices that do not meet WorkSafe's invoicing guidelines for medical practitioners