Section A: Fees for Admitted Patients

6 WorkSafe (formerly WorkCover) Patients

WorkSafe payment rates for admitted patients are listed below:

Processing of accounts by WorkSafe insurers

Account enquiries can be addressed to the relevant WorkSafe agent or claimants employer. Agent details are available on the WorkSafe website at www.workcover.vic.gov.au

6.1 Fees

Fees for WorkSafe compensable separations will be based on AR-DRGs with Victorian modifications (VICDRG) and the Victorian Department of Human Services cost weights specified below. The formula for calculating weighted inlier equivalent separations will be the same as the general hospital case-mix funding formula as set out in the Department of Human Services Victoria - Public Hospitals and Mental Health Services Policy and Funding Guidelines as amended from time to time. Those Guidelines are available at www.health.vic.gov.au/pfg/

6.2 Admission criteria

Acute admitted patients
WorkSafe compensable patients should only be admitted to hospital in accordance with the Minimum Criteria for Admission as specified in. the current DHS Admission Policy available at: www.health.vic.gov.au/hdss/vaed/vaedcomms.htm

Rehabilitation patients
Fees may be raised for WorkSafe compensable patients admitted for same-day rehabilitation for provision of same day treatment. Criteria for admission as a same day admitted patient are that the patient:

• attends a rehabilitation program designated for payment purposes by the Department; and
• attends for two or more therapy interventions; and
• receives treatment for a period of four hours or more.

Where these criteria are not met, the fees raised for attendance for rehabilitation would be in accordance with the appropriate non-admitted patient fee rate.
Fees for patients admitted to Designated Rehabilitation Programs will be in accordance with the DHS ("the Department") payment schedule as set out in section 6.3 below, Description of Fees. The Department’s most current VAED Manual as may be amended from time to time, lists Designated Rehabilitation Programs for the purpose of Care Type P, 2, 6 or 7 - see also specification changes to the manual at www.health.vic.gov.au/hdss/vaed/

6.3 Description of fees

Acute admitted patient fees for WorkSafe compensable admissions are charged to reflect the average cost of services provided as described by the patient's VICDRG.

Base fee
The Department has agreed new admitted patient rates for Worksafe patients applicable from 1 July 2009 to 30 June 2010.

For 2009 -10 WorkSafe separations from 1 July 2009 to 30 June 2010 the base WIES price of $ 3,810 will apply.

For WorkSafe separations from 1 July 2008 to 31 December 2008 the base WIES price is $3544.

For Worksafe separations from 1 January 2009 to 30 June 2009 the base WIES price is $3670.

To calculate the acute admitted patient fee, the base fee is multiplied by the appropriate Weighted Inlier Equivalent Separation (WIES) value. Medical practitioner costs are excluded from the fee.

Rehabilitation
The following fees apply for patients admitted to rehabilitation programs designated by the Department of Human Services.

Mental Health admitted rates

WorkSafe will pay the public bed day rates for all inpatient mental health services as published annually in the Victoria – Public Hospitals and Mental Health Services Policy and Funding Guidelines.

Reference: Circular 13/2006

Other Admitted Services

WorkSafe will pay for all other admitted services at the published public rate.

6.4 Definitions of inliers and outliers for VWA compensable separations

Definitions for inliers and outliers for WorkSafe admitted patients are those published in the Departments; Victoria - Public Hospitals & Mental Health Services Policy and Funding Guidelines, as may be amended from time to time.

6.5 Provisional statements

Provisional statements may be issued for high outlier patients whose length of stay exceeds 35 days. A provisional VICDRG statement may be generated by the hospital's own accounts system based on the provisional VICDRG to which a patient would be grouped and according to the program logic for per diem inlier equivalence of high outlier days. A final WorkSafe admitted patient VICDRG Statement for the entire patient episode will be produced during processing of PRS/2 transmissions following separation of the patient. In addition, hospitals may raise progressive invoices for patients admitted to designated rehabilitation programs.

6.6 WorkCover Statement & forwarding of invoices

Under the agreement with VWA, hospitals are required to provide details as set out below in the `Admitted Patient VICDRG Statement'.

Also, public hospitals will need to obtain the following information for invoicing purposes:

worker's name and claim number; and
name of the Authorised Insurer.

This information should be available from the worker or the employer. Once the invoice has been raised, it should be sent to the relevant authorised insurer, unless the employer is a registered self-insurer in which case it should be sent direct to the employer.

In addition, public hospitals will need to obtain the following information for invoicing purposes. VWA requires a principal diagnosis from Volume 3 of the International Classification of Diseases, 10th Revision, Australian Modification coded in accordance with the Australian Coding Standards (ICD-10-AM Vol 5) for every admitted patient. Other codes may be provided in addition to this primary requirement.

6.7 Magnetic Resonance Imaging Fees for Workcover Patients

Compensable patients may be charged a single fee of $575 for an MRI service. VWA has adopted the Medicare Benefits Schedule (MBS) eligibility requirements in relation to MRI providers, equipment and services.

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