Billing review program for dental providers

The TAC and WorkSafe Victoria can pay the reasonable costs of medical and allied health services required by TAC clients and injured workers because of their transport accident or work-related injury or illness.

Why do the TAC and WorkSafe have a provider billing review?

The TAC and WorkSafe conduct periodic reviews of payments made to providers, including dental providers, for medical and allied health services to TAC clients and injured workers through the Billing Review Program.  The primary focus of the program is to ensure that payments made to medical and allied health providers are appropriate and comply with the TAC and WorkSafe policies and fee schedules.

The TAC and/or WorkSafe may review payments made to you for services provided to TAC clients or injured workers at any time.

How is the billing review program different to reviews by the Clinical Panel?

The TAC and WorkSafe Clinical Panels comprising medical, allied healthcare and dental practitioners, review the services provided to TAC clients and injured workers to ensure that they are clinically justified and improve health and return-to-work outcomes.

The TAC and WorkSafe Billing Review Program focuses, instead, on ensuring that payments made to dental providers are appropriate. Clinical advice is obtained by the TAC and WorkSafe when completing billing reviews.

How will I be notified of a review?

When seeking information directly from a dental provider as part of the Health Practitioner Billing Review Program, the TAC and WorkSafe may formally notify you of a requirement for patient health information and documents relating to a TAC or WorkSafe injury pursuant to section 127A of the Transport Accident Act 1986 and/or section 552 of the Workplace Injury Rehabilitation and Compensation Act 2013. These sections of the legislation provide the authority for the requested patient health information and documents to be supplied to the TAC and/or WorkSafe.  As such, a dental provider is not required to obtain patient consent in order to release the required patient information and documents under these provisions.

The TAC or WorkSafe will contact you about a review before a visit, and arrange a time to collect the required information and documentation that is convenient to you.  If copies are not available at the time of collection, documentation can be taken for copying and returned to you within an agreed timeframe.  Both the TAC and WorkSafe may also contact other parties to obtain information and documentation, including hospitals and other health facilities, to assist with the billing review.

The TAC and WorkSafe seek to communicate and obtain requested information and documentation from dental providers in a co-operative way.

In some circumstances, the TAC and WorkSafe also have the authority to inspect, examine or make extracts from, or copies of any information within premises that may be required to complete a billing review.

The information and documentation obtained by the TAC and WorkSafe are not utilised by claim staff in the management of TAC client or injured worker claims.

What about confidentiality and secure storage of patient information?

The TAC and WorkSafe appreciate any concerns dental providers may have with respect to the security of confidential patient information. The TAC and WorkSafe are required to comply with the Information Privacy Act 2000 (Vic.), the Health Records Act 2001 (Vic.) and the Information Privacy Principles and Health Privacy Principles set out in those Acts. Patient information collected from dental providers as part of the Billing Review Program is not placed on claim files and is managed in accordance with the TAC's and WorkSafe'sprivacy policies.

What is considered in a review?

A TAC or WorkSafe billing review focuses on ensuring that payments made to dental providers are appropriate and comply with the TAC and WorkSafe policies and fee schedules.  The TAC and WorkSafe consider billing data, client/worker information, clinical records, attendance records, other supporting information and documentation along with the relevant policies and fee schedules when conducting reviews.  The TAC and WorkSafe rely on clinical advice from appropriately qualified peer clinicians during a billing review.

Who will I be dealing with?

If payments made to you are under review, you may receive requests for information from a representative of the TAC’s Forensics Group or WorkSafe’s Enforcement Group.

How long will the review process take?

The review process can take up to several months to complete, depending on the time taken to collect the required information and the number of reviews undertaken at any one time.  The TAC and WorkSafe endeavour to communicate any issues identified as part of the review and to seek any necessary clarifications from providers as soon as practicable.  The TAC and WorkSafe also encourage providers to communicate with either organisation or their professional bodies if they have any queries.

What happens at the end of my review?

At the conclusion of a review, the TAC or WorkSafe will communicate with the dental provider about the outcome of the review.  Potential outcomes include one or more of the following:

  • no further action taken
  • a request for explanation
  • a request for reimbursement of any incorrect/inappropriate payments
  • referral/notification to the relevant regulatory body, and/or
  • referral for investigation.

Where appropriate, the TAC and WorkSafe will provide practical and constructive advice about how to comply with a relevant policy or billing rule.

Where professional conduct issues are identified, the TAC or WorkSafe may also propose referral of the issues identified to the Australia Health Practitioners Regulation Agency (AHPRA) for review and are able to suspend your payments for services provided to TAC clients and injured workers pending the outcome of the AHPRA review.  Prior to a referral or notification to the AHPRA, the TAC and WorkSafe will give the dental provider an opportunity to respond to the issues identified.  Any response received will be taken into consideration when determining whether a referral to the AHPRA is appropriate.

Payment reconciliation/self-audit

The TAC and WorkSafe encourage all providers to reconcile payments with invoices and to review their billing practices relating to TAC and WorkSafe claims as a matter of course.

If, during a self-audit, you discover any billing errors or incorrect billing practices in relation to services provided to TAC clients or injured workers, you should contact the TAC on freecall 1300 654 329 or toll free on 1800 332 556, or email info@tac.vic.gov.au or WorkSafe’s Advisory Service on freecall 1800 136 089 or (03) 9641 1444, or email info@worksafe.vic.gov.au

Where can I get more information?

You can contact Mr Greg O’Neil, Manager, Forensic Accounting and Review at the TAC on (03) 5225 7098 or Ms Rosetta Spano, Audit and Analysis at WorkSafe on (03) 9940 4843 if you have any queries regarding the Billing Review Program.

Find out more in the TAC provider guidelines for your discipline and our fee schedules. WorkSafe information is available on their website at worksafe.vic.gov.au.

If you have any specific queries about TAC or WorkSafe policies and fee schedules, please contact the: