WorkSafe patients

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.

Fees

Worksafe and the Department of Health (DH) apply a common set of principles to set fees. The principles are simplicity and transparency, methodological consistency with the DH Policy and Funding Guidelines (where possible), activity based (where possible), equitable, efficient and effective, full cost recovery and budget predictability.

On 1 July 2021, Victoria transitioned to the National Weighted Activity Unit (NWAU) funding model. The WorkSafe has also transitioned to NWAU based payments for admitted activities. The classifications on which these payments are made are: for acute admitted activity, the Australian Refined Diagnosis Related Group and for admitted emergency activity, the Australian Emergency Care Classification. The WorkSafe NWAU is the same NWAU calculated for public hospital funding. NWAU calculators are produced by the Independent Hospital Pricing Authority and are available on their website.

Admission criteria

Acute admitted patients

WorkSafe compensable patients should only be admitted to hospital in accordance with the VAED Criteria for reporting which establishes the criteria for admission. The updated policy is available at Victorian Admitted Episodes Dataset.

Admitted emergency patients

WorkSafe compensable patients that have met the criteria for admission may have transitioned through the emergency department. These patients must be reported to the VEMD and meet the reporting requirements outlined in the Victorian emergency minimum dataset. To be eligible for admitted emergency NWAU payment, the WorkSafe compensable patient record must be coded with an admitted departure status, specifically, VEMD departure status in (‘03’, ‘14’, ‘15’, ‘18’, ‘22’, ‘25’, ‘26’, ‘27’, ‘28’ or ‘31’).

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 DH; 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 DH payment schedule as set out below. The Department’s most current VAED Manual, lists Designated Rehabilitation Programs for the purpose of Care Type P or 6 . Also refer to specification changes to the manual at Victorian Admitted Episodes Dataset.

Description of fees

The Department has agreed admitted patient rates for Worksafe patients.

Admitted acute payment rate

To calculate the acute admitted patient fee, the base fee is multiplied by the appropriate National Weighted Activity Unit (NWAU) value. That approach likewise applies for the NWAU that might arise from the admitted emergency activity associated with that patient. Medical practitioner costs are excluded from the fee.

Emergency department only attendance fee

Worksafe compensable patients that are not admitted but attended to in public hospital emergency departments attract an attendance fee. This fee can not be claimed if the patient is eligible for an admitted emergency payment (see guidance on eligibility in the Admitted emergency patients section). Specifically, an emergency patient claim can only be made once for a WorkSafe compensable patient as either an ED only rate, or as an admitted emergency NWAU rate.

WorkSafe should continue to be billed separately for diagnostic and medical services provided in Emergency Departments.

ED only attendance rate

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

Rehabilitation payment rates

Other rates

The following rates apply for other admitted, non-admitted and miscellaneous categories.

Other admitted rates

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

Specialty Clinics

*WorkSafe code PMEP01

# 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.

Mental Health - non admitted

Diagnostic imaging rates

Medical reports rates

Provisional statements

Provisional statements may be issued for high outlier patients whose length of stay exceeds 35 days. A provisional DRG statement may be generated by the hospital's own accounts system based on the provisional DRG 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 DRG 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 VAR-DRG Statement' and 'Emergency Presentation AECC 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.