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Elective Surgery

This policy is inclusive of non-emergency surgical treatment only

March 2012
The WorkSafe Agent can pay the reasonable costs of elective surgery when required as a result of a work-related injury or illness when the service is provided by a registered medical practitioner in accordance with section 99 of the Accident Compensation Act 1985. WorkSafe adopts the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions for surgical services provided by suitably qualified medical practitioners. This policy must be read in conjunction with the following documents: Medical Practitioner Policy Reimbursement Rates for Medical Services Surgically Implanted Prostheses Policy Medicare Benefits Schedule (MBS). For implantable pain therapy, please also refer to the Implantable Pain Therapies Policy. surgically implanted prosthetic items as listed on the current Prostheses List published by the Department of Health and Ageing (DoHA) and in accordance with the Surgically Implanted Prostheses Policy.

What information does the Agent require to consider paying for elective surgery?
Written approval from the Agent is required prior to elective surgery being performed. To facilitate a timely decision on the request and to ensure the most appropriate services are provided to the worker, the Agent requires a written request from the medical practitioner that includes: name and claim number of the worker name of medical practitioner performing the elective surgery brief description of the specific elective surgery requested clinical indication for the elective surgery and the relationship between the surgery and the work-related injury or illness anticipated prosthesis details, if required. If this is a gappermitted or unlisted prosthesis, written clinical justification is required - please refer to WorkSafes Surgically Implanted Prostheses Policy. The Agent will accept the above information in a letter from a surgeon to a third party, for example, the referring GP. This should be provided to the Agent with notification from the surgeon clearly starting that this is a request for funding.

Definition
What is elective surgery?
In this policy, elective surgery is clinically necessary, nonemergency surgical treatment (including surgical procedures) performed by a registered medical practitioner.

Guidelines
What can the Agent pay for in relation to elective surgery?
The 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 hospital and theatre fees in accordance with the relevant and current WorkSafe private hospital fee schedule

When will I receive a response from the Agent?


Within 10 working days of receiving the elective surgery request, the Agent will advise whether: the request has been approved the request has been denied further information is required to make a decision. Where further information is required, the Agent will advise whether the elective surgery request has been approved or denied within 10 working days of receiving the additional information.

Note: This policy is a guideline issued by WorkSafe Victoria under the Accident Compensation Act 1985 (the Act) in respect of the reasonable costs of services under Division 2B of Part IV of the Act (section 99AAA(2)(c)(iii)) and services for which approval should be sought from the WorkSafe Agent or self-insurer (as the case may be) before the services are provided (section 99(2)). WSV1405/02/03.12

Policy for Elective Surgery

What invoicing information does the Agent require 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 on the information required when submitting invoices to the Agent for elective surgery, please refer to How to Invoice WorkSafe.

Further Information
Contact the referring Agent, email info@worksafe.vic.gov.au or refer to: Accident Compensation Act 1985 Reimbursement Rates for Medical Services Private hospital fee schedules How to Invoice WorkSafe Medical Practitioner Policy Implantable Pain Therapy Policy Surgically Implanted Prostheses Policy Private Hospital Policy Online Claims Manual (refer to Chapter 10.5.11) Medicare Benefits Schedule

What fees are payable for elective surgery?


The 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 Healths Fees Manual minimum price of surgically implanted prosthetic items as listed on the Prostheses List.

In relation to elective surgery what will the Agent not pay for?
The 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 services for a condition that existed before the workrelated injury or illness or that is not a direct result of the work-related injury or illness treatment or services where there is no objective evidence that a treatment or service is safe and effective 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 workers, and between other providers, including hospitals treatment/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 medical practitioner invoices that do not meet WorkSafes Invoicing guidelines for medical practitioners.