Medical practitioners fees order 2015

under the Workers Compensation Act 1987

I, VIVEK BHATIA, Chief Executive Officer of the WorkCover Authority of New South Wales, make the following Order pursuant to section 61 (2) of the Workers Compensation Act 1987.
Dated this 4th day of December 2014

VIVEK BHATIA
Chief Executive Officer
WorkCover Authority

Explanatory Note

Treatment by a Medical Practitioner is one of the categories of medical or related treatment covered under the Workers Compensation Act 1987.
Injured workers are not liable for the cost of any medical or related treatment. Employers are liable for the cost of treatment.
This Order sets the maximum fees for which an employer is liable under the Act for treatment by a Medical Practitioner of an injured worker's work-related injury.
In accordance with section 60 (2A) of the Workers Compensation Act 1987, medical or related treatment requires prior insurer approval unless exempt from pre-approval under the Workers Compensation Act 1987 or the WorkCover Guidelines for Claiming Compensation Benefits in effect at the time.
Consulting Surgeons should refer to the Workers Compensation (Orthopaedic Surgeon Fees) Order 2015 and the Workers Compensation (Surgeon Fees) Order 2015.
This Order adopts the List of Medical Services and Fees published by the Australian Medical Association (AMA), except where specified in this Order. To bill an AMA item, a Medical Practitioner must be confident they have fulfilled the service requirements as specified in the item descriptor. Where a comprehensive item is used, separate items cannot be claimed for any of the individual items included in the comprehensive service.
The incorrect use of any item referred to in this Order can result in penalties, including the medical practitioner beingrequired to repay monies to WorkCover that the practitioner has incorrectly received.

Workers Compensation (Medical Practitioner Fees) Order 2015

1. Name of Order


This Order is the Workers Compensation (Medical Practitioner Fees) Order 2015

2.Commencement

This Order commences on 1 January 2015.

3. Definitions

In this Order:

  • the Act means the Workers Compensation Act 1987.
    AMA List means the document entitled List of Medical Services and Fees published by the Australian Medical Association and dated 1 November 2014.
  • Assistant at Operation means a Medical Practitioner, but only where an assistant's fee is allowed for in the Commonwealth Medical Benefits Schedule, or where indicated in the WorkCover Order or approved in advance by the insurer. An assistant fee may only be applicable for surgical procedures EA010 to MY115.
    In accordance with NSW Health policy (File No. C17061, Doc No.: PD2005_018), assistant fees cannot be charged for WorkCover cases performed in a public hospital when the assistant is a Registrar. If the Registrar is on rotation to an approved private hospital, the relevant assistant fee may be charged. Payment of these fees is to be directed into a hospital or departmental trust fund account and the invoice should include details of this account. Workcover reserves the right to conduct an audit of assistant fee payments to ensure their proper distribution into the named trust fund.
  • Case conference means discussions additional to that required for the management of patients with comparable injuries/conditions that are not compensable. Case conferencing can be via a face-to-face meeting, video conference or teleconference with any or all of the following parties – workplace rehabilitation provider, employer, insurer or other treatment provider delivering services to the worker – to assist the worker to stay at or return to work. If the discussion is with the worker, it must involve a third party to be considered a Case conference. Discussions between treating doctors and practitioners relating to treatment are considered a normal interaction between referring doctor and practitioner and are not to be charged. File notes of Case conferences are to be documented in the Medical Practitioner's records indicating the person/s spoken to, details of discussions, duration of the discussion and outcomes. This information may be required for invoicing purposes.
  • Consulting Surgeon means a Medical Practitioner who holds a fellowship of the Royal Australasian College of Surgeons or is currently a Fellow of the Australian Orthopaedic Association. It includes a Surgeon or Orthopaedic Surgeon who is recognised by Medicare Australia as a Specialist Surgeon or Specialist in orthopaedic surgery. It also includes a Surgeon or Orthopaedic Surgeon who is a staff member and provides services at a public hospital.
  • GST means the Goods and Services Tax payable under the GST Law;
  • GST Law has the same meaning as in the A New Tax System (Goods and Services Tax) Act 1999 (Cth).
  • Medical Practitioner means a person registered under the Health Practitioner Regulation National Law (NSW) No 86a in the medical profession.
  • Medical Specialist means a Medical Practitioner recognised as a specialist in accordance with the Health Insurance Regulations 1975, Schedule 4, part 1, who is remunerated at specialist rates under Medicare.
  • Out-of-hours services only apply in an emergency where the clinic is not normally open at that time, and urgent treatment is provided. This fee is not to be utilised in the situation where a consultation is conducted within the advertised hours of a clinic.

4. Application of Order

This Order applies to treatment provided on or after the commencement date of this Order, whether it relates to an injury received before, on, or after that date.

5. Maximum fees for Medical Practitioners

(1) This clause applies to medical and related treatment provided by a Medical Practitioner in respect of which a fee is specified in the AMA List, except:

a. Medical services identified in the AMA List by AMA numbers AC500, AC510, AC520, AC530, AC600 and AC610 (Professional Attendances by a Specialist), if these medical services are provided by a Specialist Surgeon;
b. Medical services identified in the AMA List by AMA Numbers EA010 to MZ705 (Surgical Operations) if these medical services are provided by a Specialist Surgeon;
c. Medical services identified in the AMA List by AMA Number MZ900 (Assistant at Operation fee);
d. Medical services identified in the AMA List by AMA numbers OP200, OP210 and OP220 (magnetic resonance imaging – MRI).

(2) The maximum amount payable for magnetic resonance imaging (MRI) is:
* $700 for one region of the body or two contiguous regions of the body $1050 for three or more contiguous regions of the body, or two or more entirely separate regions of the body
(e.g. wrist and ankle).
(3) The maximum amount payable for a certificate of capacity is $44.50. This fee is payable only once per claim for
completion of the initial certificate of capacity.
(4) The maximum hourly rate payable to a:
* General Practitioner is $266.40 or $22.20 per 5 minutes
* Medical Specialist is $369.60 or $30.80 per 5 minutes
* Consulting Surgeon is $489.60 or $40.80 per 5 minutes.
These fees are to remunerate for any time spent by the Medical Practitioner/Medical Specialist/Consulting
Surgeon, in addition to the usual medical management, to assist the worker stay at or return to work. These rates
may cover, for example, discussions with employers, case conferences, visits to worksites, time spent reviewing
injury management or return to work plans and providing additional reports requested from treating doctors and
pre-approved by the insurer. These should be billed under the WorkCover payment classifi cation code WCO002
and reflect the time taken (to the nearest 5 minutes) to deliver the service.
Note: No fee is payable for liaison with other health providers involved in the treatment of the injured worker
(e.g. Medical Specialists, allied health providers) unless the communication is additional to that required
for the management of patients with comparable injuries/conditions that are not work related.
(5) The maximum fee for providing hard copies of medical records (including Medical Specialists' notes and reports)
is $36 (for 33 pages or less) and an additional $1.30 per page if more than 33 pages. This should be billed under
WorkCover payment classifi cation code WCO005.
(6) Subject to subclauses (1), (2), (3), (4), (5), and clause 7 (Nil fee for certain medical services), the maximum amount
for which an employer is liable under the Act for any claim for medical or related treatment to which this clause
applies is the fee listed, in respect of the medical or related treatment concerned, in the AMA List.
6. Specialist consultations
The initial Medical Specialist/Consulting Surgeon consultation fee includes the first consultation, the report to the
referring General Practitioner and the copy of the report to the insurer.
The report will contain:
a. The patient's diagnosis and present condition;
b. The patient's likely capacity for pre-injury employment or suitable employment;
c. The need for treatment or additional rehabilitation; and
d. Collateral conditions that are likely to impact on the management of the worker's condition (in accordance with
privacy considerations).
Consultations with Medical Specialists/Consultant Surgeons require prior approval by the insurer unless exempt from
pre-approval by the Act or the WorkCover Guidelines for Claiming Compensation Benefits in effect at the time. Any
reports from ongoing consultations should be sent to the referring General Practitioner and copied to the insurer.
Additional reports requested that do not relate to the routine management of a worker's injury and not required as
part of a dispute or potential dispute should be billed under WCO002 at a rate of $369.60 per hour or $30.80 per 5
minutes (plus GST) for Specialists or $489.60 per hour or $40.80 per 5 minutes (plus GST) for Consulting Surgeons.
The hourly rate is to be pro-rated into 5 minute blocks to reflect the time taken to prepare the report. These reports
may answer questions to assist the insurer determine prognosis for recovery and timeframes for return to work. If the
report is requested as part of a current or potential dispute (for example, when there is lack of agreement regarding
liability, causation, capacity for work or treatment between key parties) and the treating medical practitioner is requested
to provide their opinion, the Workplace Injury Management and Workers Compensation (Medical Examination and
Reports Fees) Order 2015 applies.
7. Nil fee for certain medical services
The AMA List includes items that are not relevant to medical services provided to injured workers. As such, the fee
set for the following items is nil:
a. General Practitioner – Urgent attendances after hours items (Medical services identified in the AMA List by AMA
number AA007)
b. All time based General Practitioner fees items (Medical services identified in the AMA List by AMA numbers
AA190 – AA320)
c. Enhanced primary care items (Medical services identified in the AMA List by AMA numbers AA501 – AA850)
d. All shared health summary items (Medical services identified in the AMA List by AMA numbers AA340 – AA343)
e. Telehealth items (Medical services identifi ed in the AMA List by AMA numbers AA170 – AA210 and AP050 –
AP105).

Note: Whilst telephone consultations with injured workers are discouraged and do not attract a fee, video consultations
are permissible when approved in advance by the insurer. Insurers will consider if the video consultation is
reasonably necessary, appropriate and likely to be effective when making a decision whether to approve these
services. Video consultation treatment services are to be paid in accordance with the consultation items in this
Order.
No fee is payable for cancellation or non-attendance by a worker for treatment services with a Medical Practitioner/
Medical Specialist/Consultant Surgeon.
8. Goods and Services Tax
An amount fixed by this Order is exclusive of GST. An amount fixed by this Order may be increased by the amount of
any GST payable in respect of the service to which the cost relates, and the cost so increased is taken to be the amount
fixed by this Order. This clause does not permit a Medical Practitioner/Medical Specialist/Consultant Surgeon to charge
or recover more than the amount of GST payable in respect of the service to which the cost relates.
9. Requirements for invoices
All invoices must be submitted within 30 days of the service provided and must comply with WorkCover's itemised
invoicing requirements in order for the invoice to be processed.
10. No pre- payment of fees
Pre-payment of fees for reports and services is not permitted.

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