Processing of accounts by WorkSafe insurers
Worksafe and the Department of Health and Human Services (DHHS) apply a common set of principles to set fees. The principles are simplicity and transparency, methodological consistency with the DHHS Policy and Funding Guidelines (where possible), activity based (where possible), equitable, efficient and effective, full cost recovery and budget predictability.
Acute admitted rates for WorkSafe compensable separations are based on AR-DRGs with Victorian modifications (VICDRG) and the DHHS cost weights. The formula for calculating weighted inlier equivalent separations is the same as the general hospital case-mix funding formula as set out in the DHHS Policy and Funding Guidelines as amended from time to time. Those Guidelines are available at policy and funding guidelines.
Acute admitted patients
WorkSafe compensable patients should only be admitted to hospital in accordance with the Criteria for Admission as specified in the Victorian Admitted Episodes Dataset: Criteria for Reporting as amended from time to time. The document is available at .
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 DHHS; 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 DHHS 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 or 6 - see also specification changes to the manual at .
Description of fees
The Department has agreed new admitted patient rates for Worksafe patients applicable from 1 July 2020 to 30 June 2021.
WIES payment rate
|WorkSafe WIES Price||1 July 2019 - 30 June 2020||1 July 2020 - 30 June 2021|
|Applicable Victorian Cost Weights||WIES 26||WIES 27|
|Base WIES Price||$5,155||$5,516|
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.
Emergency department only attendance fee
Worksafe patients attended to in public hospital emergency departments attract an attendance fee.
Worksafe should continue to be billed separately for diagnostic and medical services provided in Emergency Departments.
Inpatient admissions will not be permitted within the Emergency Department.
ED only attendance rate
|Worksafe item code||Emergency Department fee||1 July 2019 - 30 June 2020||1 July 2020 - 30 June 2021|
|PUB100||ED only attendance fee||$277||$284|
The following fees apply for patients admitted to rehabilitation programs designated by the Department of Health and Human Services.
Rehabilitation payment rates
|Worksafe item code||Grouping||Rehabilitation||Care type||1 July 2019 - 30 June 2020 per bed day||1 July 2020 - 30 June 2021per bed day|
|RESP01||Spinal Austin only||Level 1||Spinal||$1,309||$1,342|
The following rates apply for other admitted, non-admitted and miscellaneous categories.
Other admitted rates
|Grouping||Other inpatient rates||Metro/Rural||1 July 2019 - 30 June 2020 per bedday||1 July 2020 - 30 June 2021 per bedday|
|Geriatric Evaluation and Management||$670||$687|
|Nursing Home Type - Patient/Day||$263||$270|
|Palliative care - Admitted||Metro||$685||$702|
|Specialty clinics||Pain Management Inpatient||$719||$737|
|Rehabilitation in the Home - Inpatient Equivalent||$504||$517|
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.
Other non-admitted rates
|Worksafe item code||Grouping||Non-admitted patients||Specifics||1 July 2019 - 30 June 2020||1 July 2020 - 30 June 2021|
|N/A||Specialty clinics||Pain management||Compensable non-admitted patient fees for outpatients as per DHHS Funding and Policy Guidelines|
|PMEP01||Pain education program|| |
Price per program
# Refer policy
|Kingston - 1 Assessment||$1,581||$1,621|
|Kingston - 2 Assessment||$2,370||$2,429|
|N/A||Rehab in the home||Compensable non-admitted patient fees for outpatients as per DHHS Funding and Policy Guidelines|
|N/A||Mental health||Clinical Community Care||Group per visit||$161||$165|
|N/A||Individual per visit||$276||$283|
# Pain Education Program (Non-admitted)
Pain education programs are 8-10 hour multi-disciplinary group education programs. To deliver this service, Worksafe must approve the provider and their pain education program. Worksafe's current approved providers are Austin Health, Barwon Health and St Vincent's Hospital.
Diagnostic imaging rates
|Report type||Amount Worksafe will reimburse hospital|
|MRI||As listed in the Worksafe fee schedule Medical Practitioner Services. The rates payable depend on the MBS item billed in relation to the MRI procedure undertaken.|
|Other diagnostic imagining services|
Medical reports rates
|Worksafe item code||Report type||Amount Worksafe will reimburse hospital||Conditions/details|
|N/A||Standard Discharge Report||$0||Hospitals may not bill for standard discharge reports.|
|MEDRPT||Medical report||This report is prepared by a public hospital's medical officer as opposed to the treating medical practitioner.||$432|
|HOSRPT||Hospital report||The report is prepared by clerical staff on behalf of the public hospital's medical officer and provides a summary of the medical record.||$259|
|PUBFOI||FOI request from Worksafe to access medical reports||Reasonable costs incurred||Public hospital may charge Worksafe for the reasonable costs incurred in making those arrangements as prescribed in the FOI Act and the Freedom of Information Access Charges Regulations 2004 (Regulaitons).|
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.
WorkSafe statement and forwarding of invoices
Under the agreement with Worksafe, 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. Worksafe requires a principal diagnosis from Volume 1 of the International Classification of Diseases, 10th Revision, Australian Modification coded in accordance with the Australian Coding Standards for every admitted patient. Other codes may be provided in addition to this primary requirement.
WorkCover Admitted Patient VICDRG Statement
Patient UR No.
Date of birth
Admitted Patient Stay:
Date of admission:
Length of stay:
Hospital in the Home Length of Stay
VICDRG base fee
Separation type code
Acute Admitted Patient Fee
Descriptions are provided for the primary diagnoses, sequalae diagnoses and operation codes only
This is not an invoice. It must be attached to a hospital invoice before dispatch to VWA
Reviewed 24 February 2016