How to reduce your out of pocket medical costs if you’ve been injured at work

When you’re injured at work, one of the main priorities is getting medical treatment so you can get onto the road to recovery. However, medical treatments can be expensive and you don’t want to be out of pocket for these costs.

That’s where WorkCover insurance comes in. WorkCover is a compulsory insurance that covers Australian employees, to provide them with benefits and financial support if they get injured or sick at work, regardless of who is at fault. Most workplaces must provide this insurance to their full-time, part-time and casual employees.

If you’ve been injured at work the first thing to do is make a WorkCover claim. You should do this as soon as possible and once your claim is accepted by the WorkCover authority, you’ll be issued with a WorkCover claim number that you can present to your treatment providers to claim for your treatments.

If you have an accepted WorkCover claim you can access a number of services without prior approval from the WorkCover insurer or a medical referral. These services are:

• Ambulance;
• Chiropractic, osteopathic or physiotherapy;
• Dental services;
• Optometry;
• Podiatry;
• MRI scans; and
• Family counselling services.

However, ongoing treatment costs for these types of services will be reviewed by the WorkCover insurer from time to time.

For treatments such as physiotherapy, osteopathy and chiropractic care, only one type of treatment will be funded at a time by the WorkCover insurer so that the effectiveness of the treatment can be monitored.

A range of other medical expenses can also be covered but require prior approval from the WorkCover insurer. Examples of these types of expenses include surgery, psychological services, pain management programs, home help and car modifications.

Generally, it’s best to speak to your WorkCover insurer first to seek prior approval for any new forms of treatment before incurring the cost to make sure you’re not left out of pocket. The best way to seek pre-approval for a treatment is to arrange for your GP or treating health practitioner to send a letter to the WorkCover insurer seeking approval for the proposed treatment with an explanation about why the treatment is required and how it’s connected to the workplace injury.

Once the request has been sent to your WorkCover insurer, the insurer has 10 days to notify you as to whether:

• the request has been accepted;
• the request has been denied; or
• if further information is required.

If further information is required, your WorkCover insurer has another 10 days after you’ve provided the information to let you know of the outcome.

It’s best to arrange for your treating healthcare provider to invoice the WorkCover insurer directly, although you could also choose to pay the invoice upfront and then seek reimbursement later. If you choose to pay the invoice yourself first, the invoice should be submitted to the WorkCover insurer within six months of the date of the service. Once the invoice has been submitted, the WorkCover insurer has 30 days to reimburse you.

If you need to travel to attend an appointment, for example you live in a rural area or need to travel to Melbourne to see a specialist, you can claim travel costs from the WorkCover insurer as well. Claims for travel cost should be submitted in the WorkCover insurer’s approved claim form.

The WorkCover insurer will generally pay/reimburse medical costs in line with the Medicare Benefits Schedule. Please note that some treating healthcare providers may charge above this rate, and in the event that they do, you will need to pay the gap. There are network providers who are contracted by WorkSafe and do not charge fees above the Medicare Benefits rates – you can ask your WorkCover insurer for a list of these providers.

In the event that the WorkCover insurer fails to reimburse your medical invoices within the allocated time, fails to make a decision about a request for treatment approval within the allowed time, or rejects approval for treatment/terminates treatment approval, you can appeal those decisions. Appeals should be made within 60 days of the failure to act or of the written decision from the insurer. If you need to appeal a decision by your WorkCover insurer, it’s a good idea to speak with a Workers Compensation lawyer first, they will be able to advise you of your rights, whether your appeal will be successful, and assist you in your appeal.