Treating and referring your patient

As a GP, it’s your responsibility to identify medical and treatment related services likely to contribute to your patient’s successful recovery.

Approval for services

SIRA’s workers compensation guide for medical practitioners states:

You may identify medical and treatment-related services likely to contribute to the worker’s successful recovery. These may include specialist treatment or workplace rehabilitation services.

Generally, approval from the insurer is required prior to the provision of medical and treatment related services. However, there are some exceptions where workers can access some services without pre-approval from the insurer.

Reasonably necessary treatments and services that do not require pre-approval

Recommended treatment

It is important to develop a recommended treatment plan for your patient, which outlines the type of treatment and intervention your patient may require.

A recommended treatment plan for your patient:

  • must be directly related to the work related injury or illness
  • should be discussed with your patient to establish clear, realistic expectations about what treatment is likely to achieve
  • should be included on the certificate of capacity so the insurer knows what services are required and what invoices to expect.

How the insurer determines what treatment will be approved

The insurer will not pay for treatment that is:

  • experimental or not evidence-based
  • not ‘reasonably necessary’
  • not contributing to an objective improvement for your patient (particularly in relation to improving their capacity to work
  • provided by a person who is not appropriately registered[MR1].

You should contact the insurer directly if you are unsure if the treatment will be approved or not.

Reviewing treatment effectiveness

Your role as a NTD will include regularly reviewing the effectiveness of your patient's treatment.

This includes:

  • Reviewing the progression of treatment
  • Encouraging a self-management approach.
  • Providing recommendations to cease or continue treatment depending on the resulting objective improvement in function or work capacity within the expected time frame.

Find out more about the importance of recovery at work

Treatments covered under workers compensation

All details regarding exemptions from pre-approval can be found in the SIRA guidelines for medical practitioners. A brief summary is provided below.

Allied Health

Certain specialist, diagnostic and allied health services are exempt from the pre-approval under NSW workers compensation. 

The following allied health services are available under workers compensation:

  • Physiotherapists
  • Chiropractors
  • Osteopaths
  • Exercise Physiologists
  • Massage therapists
  • Psychologists
  • Counsellors

Depending on the time between the injury and the onset of treatment, your patient is entitled to receive up to eight sessions of allied health treatment without prior approval from the insurer provided the treatment is performed by a SIRA-approved physical treatment practitioner, psychologist or counsellor. 

Additional treatment must be requested by the allied health provider.

Referring to a specialist

Certain specialist, diagnostic and allied health services are exempt from the pre-approval under NSW workers compensation.  

You can refer your patient to a specialist as you would in general practice.

Specialist consultations within the first three months from the date of injury will not require approval from the insurer, however all subsequent consultations will require approval from the insurer before an appointment can be made.

Referring for diagnostic investigations

Certain specialist, diagnostic and allied health services are exempt from the pre-approval under NSW workers compensation.  

You can refer your patient for diagnostic investigations, as long as the investigation is reasonably necessary as a result of the work injury.

Any plain X-rays within the first two weeks from the date of injury do not require insurer approval.

Any ultrasound, CT scan or MRI within the first three months from the date of injury (where your patient has been referred to a medical specialist for further injury management) do not require insurer approval. MRI referrals from GPs are required to meet the criteria outlined in the Medicare Benefits Schedule.

A medical specialist may refer for any diagnostic investigations within three months of the date of injury without prior approval.

Prescribing medication

All patients with a Medicare card are eligible to receive prescriptions through the PBS, regardless of whether the prescription is for a compensable injury or not.

Within one month of the date of the injury, prescription and over-the-counter pharmacy items prescribed do not require insurer pre-approval.

After one month, only items prescribed through the PBS will not require pre-approval.

All other pharmacy items not prescribed through the PBS will require pre-approval by the insurer before your patient can be compensated for the medication.

Avoiding low value practices

The Australian Faculty of Occupational and Environmental Medicine and EVOLVE have released a statement outlining five main practices and interventions that are considered low value:

  1. Do not order low back x-rays or other forms of low back imaging as part of a routine pre-placement medical examination
  2. Do not order X-rays or other imaging for acute non-specific low back pain, unless there are red flags or other clinical reasons to suspect serious spinal pathology
  3. Do not prescribe opiates for the treatment of acute or chronic pain without assessing the patient’s clinical condition, potential side effects, alternative analgesic options, work status, and capacity to perform safety-critical activities such as driving a motor vehicle
  4. Do not certify a patient as totally unfit for work unless the work absence is clinically necessary and the patient is unfit for suitable alternative or restricted duties
  5. Do not repeat chest X-rays when screening asbestos-exposed workers unless clinically indicated

Additionally, evidence and recommendations from Choosing Wisely Australia should be taken into account when treating and referring.