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The TAC Medical Excess may apply to these services |
POLICY
The TAC can pay the reasonable costs of Treating Health Practitioner (THP) (medical) reports requested by a TAC client or their legal representative to determine a client’s initial or ongoing entitlement under the Transport Accident Act 1986 (the Act).
This may be in addition to any medical reports the TAC has previously obtained to assess eligibility to entitlements under the Act. The TAC will generally make the reports it has obtained available to a client or their medical practitioner, legal practitioner or authorised guardian.
This policy is only about medical reports that are not requested by the TAC. For information about medical reports that are requested by the TAC, refer to the Treating Health Practitioner (Medical) Reports requested by the TAC policy.
DEFINITIONS
In this policy:
- a treating health practitioner (THP) is a medical practitioner or an allied health service provider who has provided treatment to a client for at least a 3 month period. However, not all allied health service providers are authorised to provide reports for clients.
- a THP report is a report for completion by a THP authorised to report on services and clinical information relating to a client’s transport accident injury. A THP report will provide information to assist in:
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- determining a client’s initial entitlements under the Transport Accident Act 1986
- determining a client’s entitlement to weekly benefits, and medical and health services
- reviewing a client’s entitlement to weekly benefits, and medical and health services
- the management of a client’s rehabilitation and return to work.
GUIDELINES
What can the TAC pay for in relation to medical reports?
The TAC can pay the reasonable costs of a non-TAC requested THP (medical) report when:
- required as a result of a transport accident injury
- obtained by a client or on behalf of a client such as by the client's solicitor
- necessary and reasonably justified
- prepared for the purposes of determining a client's eligibility for benefits under s60 of the Act or under the Impairment Protocols and/or the No Fault Protocols
- prepared by a treating medical practitioner, specialist, hospital or for medico-legal reasons and invoiced in accordance with the relevant TAC fee schedule
- the only medical report for a particular specialty in any 12-month period.
The TAC requires prior written approval to pay the reasonable costs of a non-TAC (THP) requested (medical) report when:
- there is a request for more than one medical report for a particular specialty in a 12-month period
- the medical report being provided to the TAC appears unnecessary and is not reasonably justified
- the fee for a medical report from a treating practitioner, specialist or hospital (private), requested by or on behalf of the client exceeds the TAC scheduled rate.
Before requesting a non-TAC (THP) requested medical report, a client or their legal representative must check with the TAC as to whether a medical report has already been obtained by the TAC to avoid duplication and incurring unnecessary medical report costs.
Who can provide a medical report?
A THP medical report can be provided by:
- Medical Practitioners (e.g. general practitioners, psychiatrists, specialist physicians)
- Dentists
- Optometrists
- Physiotherapists
- Chiropractors
- Osteopaths
- Podiatrists
- Psychologists
- Neuropsychologists
- an appropriate person employed by a private or public hospital.
What information does the TAC require to consider paying for a non-TAC (THP) requested medical report?
The TAC requires a copy of the report to be provided with the invoice. This should also include copies of any other documents used in the preparation of the original report, e.g. a copy of the radiologist’s reports or photographs, etc.
Where prior written approval is required, the request for approval should be made in writing to the relevant TAC claims employee responsible for the client’s claim prior to the report being generated. Additional supporting information justifying the request may be required. See also ‘One Off Reports That Involve Exceptional Circumstances’ in the Criteria for Medical Consultants Higher Fee Rate policy.
When will the TAC respond to a request?
The TAC will respond to written treatment and service requests as set out in the TAC Service Charter.
What fees are payable for medical reports?
The TAC can pay for medical reports in accordance with:
- the relevent Medical Reports (Non TAC Requested) fee schedule
- Hospitals – Private (Non Arrangement) fee schedule for non contracted private hospitals
- Table 7 Medical Report Fees at http://www.health.vic.gov.au/feesman/fees5.htm for Public Hospitals.
For contracted private hospitals the report will be paid in accordance with the fee specified in the individual hospital's contract.
What won't the TAC pay for in relation to non-TAC (THP) requested medical reports?
The TAC will not pay for:
- treatment or services for a person other than the client
- treatment or services subcontracted to, or provided by, a non-registered provider
- the same medical report more than once. i.e. multiple copies
- where the THP only provides a copy of their clinical notes
- medical reports obtained solely for common law purposes. Costs incurred for these reports should be included in the disbursements for any successful common law claim (refer to Common Law protocols)
- treatment or services provided outside the Commonwealth of Australia
- treatment or services provided by telephone or other non face to face mediums
- the cost of telephone calls and telephone consultations between providers and clients, and between other providers, including hospitals
- treatment or services provided more than two years prior to the request for funding except where the request for payment is made within three years of the transport accident. Refer to the Time Limit to Apply for the Payment of Medical and Like Expenses policy.
- THP reports obtained for medico-legal purposes - these must be obtained by an independent examiner through the Joint Medical Examination Process.