Medical Practitioners

This policy must be read in conjunction with the:

• Medicare Benefits Schedule (MBS)
• Clarification of Medicare Benefits Schedule (MBS) rules
• relevant TAC policies outlined within the 'Medical Practitioners' section of the TAC website and the
• TAC Reimbursement Rates For Medical Services information sheet and the TAC fee schedule.

SURGICAL PROCEDURES
ELECTIVE NON SURGICAL IN-PATIENT ADMISSIONS

Policy

The TAC can fund the reasonable cost of services provided by a medical practitioner for injuries sustained in a transport accident.

Transport Accident Act 1986 references: s.3 'medical service' and s.60

The TAC has adopted the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions for services provided by medical practitioners.

When billing for medical services, medical practitioners are expected to adhere to the MBS rules unless otherwise specified by the TAC in this policy, other TAC policies within the 'Medical Practitioners' section of the TAC website, or the TAC Reimbursement Rates For Medical Services information sheet  PDF, 0.11MB.

Definition

In this policy:

• a medical practitioner means a person registered under the Health Practitioner Regulation National Law to practice in the medical profession (other than as a student) and includes a general practitioner (GP).
• a GP Return to Work Case Conference is a meeting organised and coordinated by a TAC coordinator, authorised vocational rehabilitation provider or the certifying GP to improve communication and a client’s Return to Work (RTW) outcomes. It includes those involved in the RTW process, the client, certifying GP, employer, TAC coordinator and authorised vocational rehabilitation provider to discuss return to work barriers and opportunities. Although it is preferred that case conferences are held face-to-face, they can also be held over telephone or via video.
• a GP Return to Work Phone Call is a phone consultation between a certifying GP and a client’s employer. The purpose of the call is to discuss ways to support a client stay at, or return to, work. The client is invited to participate or give consent for the call.
• a GP WorkSite Visit is a certifying GP visiting a client’s place of employment to discuss RTW opportunities with the employer, the client and/or authorised vocational rehabilitation provider. These visits are agreed to by the employer and a report from the GP is not required

Guidelines

What can the TAC pay for in relation to services provided by medical practitioners?

The TAC can:

• pay for medical services provided by a medical practitioner that have an item number in the MBS
• only pay for medical services using the Australian Medical Association (AMA) item numbers, where there is a corresponding MBS number
• only pay for medical services in accordance with the TAC Reimbursement Rates For Medical Services information sheet and the fees listed in the TAC fee schedule
• pay for services directly provided by that medical practitioner where in the case of supervision the practitioner actually attended the TAC client at the time
• pay for medical reports. Refer to the Treating Health Practitioner (Medical) Reports Requested by TAC policy and the Medical Reports Non-TAC Requested policy
• in certain circumstances, consider paying for a medical service provided by a medical practitioner that does not have a MBS item number. Refer to the Non-Established, New or Emerging Treatments and Services (NeNETS) policy.
• pay for GP participation in Return to Work Activities (RTW Case Conferences, Phone Calls with an Employer, Worksite Visits).

GP Return to Work Activities

The TAC recognises the important role that GPs play in the return to work process and encourages GPs to communicate with other stakeholders, such as the employer, the TAC and/or authorised vocational rehabilitation provider in helping a client stay at, or get back to, work. TAC can pay for GPs to:

• organise, coordinate and participate in a RTW Case Conference
• engage in a phone call with an employer to discuss RTW
• conduct a Worksite Visit; and
• use their consultation time to communicate with the client about getting back to, or staying at, work.

For more information, refer to GP Participation in Return to Work Activities information sheet and the GP Return to Work Activities Fee Schedule.

Medical Imaging

The TAC can pay the reasonable costs of medical imaging investigation services required for the diagnosis of a client's transport accident injury, for example, x-ray, CT/CAT scans, and ultrasound.

The TAC expects that the ordering of investigations is based on best practice and appropriate guidelines for managing specific conditions. Refer to the Clinical Framework for the Delivery of Health Services (Clinical Framework) for more information.

Magnetic Resonance Imaging

The TAC can pay the reasonable costs of Magnetic Resonance Imaging (MRI) when:

• referred by a medical practitioner
• required to investigate symptoms or signs that have directly arisen from a transport accident injury.

Payment of MRI services as a diagnostic test by the TAC does not constitute acceptance of ongoing liability for any subsequent procedures or treatment requested as a result of the diagnostic findings.

Invasive imaging services (including discography)

Medical practitioners can refer clients for all necessary medical imaging services, however, prior approval is required for invasive imaging procedures, such as discography.

When seeking prior approval for discography, the requesting medical practitioner must provide the following information:

• investigations conducted to date, and
• clinical justification that the client is a suitable candidate for surgery.

What billing information does the TAC require from medical practitioners?

For details on the information required when submitting invoices for medical services, refer to the TAC Invoicing Guidelines for Medical Practitioners.

What is the TAC's Billing Review Program?

For details of the TAC's Billing Review Program, refer to the Billing Review Program - Information for Medical Practitioners.

SURGICAL PROCEDURES

The TAC can fund the reasonable cost of surgical services provided by a medical practitioner for injuries sustained in a transport accident.

What can the TAC fund in relation to surgical services?

For payment of surgical services, the TAC has adopted the MBS explanations, definitions, rules and conditions for services provided by medical practitioners with the following exceptions:

Multiple Operations - Orthopaedic procedures

For orthopaedic operations set out in Group T8, subgroup 15 of the MBS (other than fractures and dislocations), the fees for two or more operations, performed on a patient on the one occasion should be calculated using the following rules:

General Orthopaedic

• 100 per cent for the item with the greatest TAC fee; plus 75 per cent of each other item.

Fractures and Dislocations

For the treatment of fractures and dislocations, the fees for two or more operations performed on a patient on the one occasion should be calculated using the following rules:

• For multiple dislocations or fractures requiring an operative or manipulative procedure, the fee for each dislocation or fracture shall be 100% of the TAC fee.
• For multiple dislocations or fractures where the second or subsequent conditions do not require operative or manipulative treatment, the fee for the second and each subsequent procedure shall be 75% of the TAC fee.
• When fractures or dislocations are associated with a compound (open) wound, an additional fee of 50% of the fracture or dislocation fee shall apply. The additional 50% applies only to the fracture or dislocation fee and does not apply to the fees for any other procedures that may be performed during the surgery. The medical practitioner must state on their invoice 'Open' or 'Compound' next to the procedure item number.
• Except where otherwise specified by the TAC, the fee for a fracture-dislocation to the same site shall be the fee for the fracture or dislocation, whichever is the greater, plus 50% of the TAC fee for the lesser procedure.

Hospital Operation Report
For any surgical procedures provided in a public or private hospital operating theatre, the principal surgeon must provide the hospital operation report generated at the time of the surgical procedure, when submitting their invoice.

Hospital operation reports will be accepted if they are either:

• the exact copy of the hospital operation report in the patient's medical file, or
• a dictated hospital operation report from the surgeon.

The following is a list of details that are expected to be included in a hospital operation report:

• Patient's name and date of birth
• Date of surgery
• Date of report
• Name of the principal surgeon
• Name of assistants
• Description of all services*, and
• Appropriate item numbers
• Signature/authorisation

* The description of all services performed needs to be adequately detailed to explain the procedure and the items invoiced. For example, the description should include the approach, procedure, closure, any prostheses used and the side and site of the procedure particularly when more than one procedure is being performed.

A hospital operation report is not required for surgical procedures that are provided outside of a hospital operating theatre (such as 'in rooms' or emergency).

Refer to the TAC Reimbursement Rates For Medical Services information sheet and the TAC fee schedule.

What information is required to request elective surgery?

The TAC requires a written request from the surgeon for elective surgery. Refer to the Surgery Requests Elective policy.

ELECTIVE NON SURGICAL IN-PATIENT ADMISSIONS

The TAC can fund the reasonable cost of elective non surgical in-patient admissions required as a result of a transport accident injury, such as in-patient rehabilitation, psychiatric, pain management, medication rationalisation or drug and alcohol services.

What information does the TAC require to fund in-patient admissions?

The TAC requires the following information in writing from the medical practitioner requesting an elective non surgical in-patient admission:

• The clinical diagnosis.
• How the diagnosis relates to the injuries sustained in the transport accident.
• Reason for the in-patient admission, and
• Proposed treatment plan.

If the initial request is via phone, or the written request does not contain sufficient information for the TAC to determine liability, the medical practitioner may be asked to provide additional information.

For in-patient admissions related to:

• pain management, refer to the Network Pain Management Programs and Pain Management Services policy.
• drug and alcohol services, refer to the Drug and Alcohol Services policy.
• urgent psychiatric admissions, funding is dependant on receipt of the following information:
  • A Request for funding of urgent psychiatric admission form, is required from the treating psychiatrist.
  • Where interim approval has been given and/or an extension to an urgent psychiatric admission is requested, the treating psychiatrist is required to contact the TAC to discuss the client's ongoing need for in-patient psychiatric treatment and may be required to provide a detailed clinical report to the TAC.
  • Upon discharge, the treating psychiatrist is required to provide a medical report to the TAC.

Can the TAC fund treatment/services provided by a member of a client's immediate family?

Refer to the Funding Treatment by a Member of a Client's Immediate Family policy.

In relation to medical practitioners, what will the TAC not pay for?

The TAC will not pay for:

• treatment or services that are not in accordance with the MBS explanations, definitions, rules and conditions for services provided by medical practitioners unless otherwise specified by the TAC
• the provision of hospital operation reports as these reports form part of the surgical service and are generated at the time of the surgical procedure
• treatment or services for a person other than the injured client
• treatment or services for a condition that existed before a transport accident or that is not a direct result of a transport accident
• treatment or services where there is no objective evidence that a treatment or service is safe and effective
• treatment or services that are of no clear benefit to a client
• non-attendance fees where a client failed to attend unless the MBS states otherwise
• GP participation in a GP RTW Case Conference that is not initiated by the TAC or vocational rehabilitation provider
• the cost of telephone calls and telephone consultations between providers and clients, and between other providers, including hospitals
• treatment or services subcontracted to a non-registered provider
• treatment or services provided outside the Commonwealth of Australia
• treatment or services provided more than 2 years prior to the request for funding except where the request for payment is made within 3 years of the transport accident. Refer to the Time Limit to Apply for the Payment of Medical and Like Expenses policy.

See also the following policies:

• Autolgous Chondrocyte Grafting requests, refer to the Non-Established, New or Emerging Treatments policy
• Bone Growth Stimulation policy
• Breast Implant Replacement policy
• Drug and Alcohol Services policy
• Functional Electronic Stimulation (FES or Neuro Muscular Electrical Stimulation) - Surgically Implanted (Internal) policy
• Hip Replacement Surgery policy
• Implantable Pain Therapy policy
• Implantable Therapy for Neurological Disorders (ITND) policy
• Laser Resurfacing (CO2 Laser Procedure) policy
• Medical Excess policy
• Medical Reports Non-TAC Requested policy
• Treating Health Practitioner (Medical) Reports Requested by the TAC policy
• Network Pain Management Programs and Pain Management Services policy
• Non-Established, New or Emerging Treatments and Services (NeNETS) policy
• Osteogenic Protein Device (also referred to as OP-1 or BMP-7) policy
• Surgery Requests Elective policy.