Workers Rehabilitation and Compensation (Scales of Medical and Other Charges) Variation Regulations 2008 (SA)

South Australia

Workers Rehabilitation and Compensation (Scales of Medical and Other Charges) Variation Regulations 2008

under the Workers Rehabilitation and Compensation Act 1986

Contents

Part 1—Preliminary

1. Short title

2. Commencement

3. Variation provisions

Part 2—Variation of Workers Rehabilitation and Compensation (Scales of Medical and Other Charges) Regulations 1995

1. Variation of regulation 3—Interpretation

2. Variation of regulation 4—Scales of charges—private hospitals and day surgery facilities

3. Substitution of Schedule 1

   Schedule 1—Scales of charges—private hospitals and day surgery facilities

   Part 1—Preliminary

   1Interpretation

   Part 2—Private hospital services

   2Rehabilitation, psychiatric and pain assessment or management services by a private hospital

   3Other private hospital services

   Part 3—Day surgery facility services

   4Day surgery facility services

   Part 4—Tables

Part 1—Preliminary

1—Short title

These regulations may be cited as the Workers Rehabilitation and Compensation (Scales of Medical and Other Charges) Variation Regulations 2008.

2—Commencement

These regulations come into operation on the day on which they are made.

3—Variation provisions

In these regulations, a provision under a heading referring to the variation of specified regulations varies the regulations so specified.

Part 2—Variation of Workers Rehabilitation and Compensation (Scales of Medical and Other Charges) Regulations 1995

4—Variation of regulation 3—Interpretation

1. Regulation 3(1)—after the definition of claims agent insert:

   day surgery facility means a facility (other than a private hospital or facility of a private hospital) designed for the provision of medical, surgical or related treatment or care on a same day basis that is declared by WorkCover by notice in the Gazette to be a day surgery facility for the purposes of these regulations;

2. Regulation 3(1)—after the definition of physiotherapist insert:

   private hospital means a private hospital within the meaning of the South Australian Health Commission Act 1976;

3. Regulation 3(1)—after the definition of psychologist insert:

   same day, in relation to a service, means a service that is provided on a single calendar day;

5—Variation of regulation 4—Scales of charges—private hospitals and day surgery facilities

Regulation 4—after "private hospitals" insert:

and day surgery facilities

6—Substitution of Schedule 1

Schedule 1—delete the Schedule and substitute:

Schedule 1—Scales of charges—private hospitals and day surgery facilities

Part 1—Preliminary

1—Interpretation

(1)In this Schedule, unless the contrary intention appears—

admission means the formal administrative process of a private hospital or day surgery facility by which the hospital or facility commences the provision of treatment, care, accommodation and other services to a patient;

admitted, in relation to a patient in a private hospital or day surgery facility, means that the patient has undergone the formal admission process of the hospital or facility and has not been discharged;

AR‑DRG means Australian Refined Diagnosis Related Group;

criteria for admission—see subclause (5);

day means a calendar day;

Day Only Procedures Manual means the Day Only Procedures Manual published in 1999 by the Commonwealth Department of Health and Aged Care, as in force on 1 January 2008;

discharge means the formal administrative process of a private hospital or day surgery facility by which the hospital or facility ceases the provision of treatment, care, accommodation and other services to a patient;

discharged, in relation to a person who has been a patient in a private hospital or day surgery facility, means that the person has undergone the formal discharge process of the hospital or facility;

inlier patient means an admitted patient whose length of stay in a private hospital for a service identified in columns 1 and 2 of Table 2—

(a)is equal to or greater than the Lower Trim Point specified in column 5 of the table corresponding to that service (or, where the Lower Trim Point is zero, is greater than the Lower Trim Point); and

(b)is equal to or less than the Upper Trim Point specified in column 4 of the table corresponding to that service;

inpatient, in relation to a private hospital, means an admitted patient who, following a clinical decision, requires or is expected to require overnight treatment for a minimum of 1 night;

length of stay, in relation to an admitted patient in a private hospital, means the number of days between the day of admission of the patient to the hospital and the day of discharge of the patient from the hospital—

(a)counting the day of admission as 1 day; and

(b)excluding the day of discharge (unless it is also the day of admission);

long stay outlier patient means an admitted patient whose length of stay in a private hospital for a service identified in columns 1 and 2 of Table 2 is greater than the Upper Trim Point specified in column 4 of the table corresponding to that service;

Manual means the Australian Refined Diagnosis Related Groups, Version 4.2, Addendum to Definitions Manual, Volume 4, produced in 2000 by the Commonwealth Department of Health and Aged Care (read with the Australian Refined Diagnosis Related Groups, Version 4.1, Definitions Manual, Volumes 1—3, produced in 1998 by the Commonwealth Department of Health and Aged Care);

short stay outlier patient means an admitted patient whose length of stay in a private hospital for a service identified in columns 1 and 2 of Table 2 for which the Lower Trim Point specified in column 5 of the table corresponding to that service is 2 or more, is less than that Lower Trim Point but greater than zero.

(2)A reference in this Schedule to a Table of a specified number is a reference to the Table of that number in Part 4 .

(3)For the purposes of this Schedule—

(a)AR‑DRG reference numbers or descriptions are as set out in the Manual; and

(b)terms and abbreviations used in AR‑DRG descriptions have the meanings given by the Manual.

(4)For the purposes of this Schedule—

(a)a charge determined in accordance with Part 2 or 3 for a service includes (where applicable) the cost of the following:

(i)accommodation;

(ii)intensive care unit;

(iii)theatre;

(iv)common use theatre items;

(v)pharmaceutical items directly related to the condition being treated;

(vi)television;

(vii)newspapers;

(viii)local telephone calls;

(ix)all hotel services (eg meals etc);

(x)consumable items;

(b)a charge determined in accordance with Part 2 or 3 for a service does not include the following costs:

(i)the cost of prostheses;

(ii)a 5% handling charge for prostheses (to a maximum of $200);

(iii)the cost of substituted high cost single use items not commonly used in Australian clinical practice for delivery of the service where the substitution for the usual item can be demonstrated to have been necessary for the treatment of the patient;

(iv)the cost of allied health treatment (such as physiotherapy, dietetics, podiatry, psychology, social work, speech pathology etc);

(v)the cost of pharmaceutical items provided on discharge of a patient;

(vi)the cost of pharmaceutical items required for a patient for maintenance of an unrelated condition;

(vii)the cost of splints and braces required for the discharge of a patient;

(viii)transfer costs;

(ix)boarder fees.

(5)For the purposes of this Schedule, a patient qualifies for admission to a private hospital or day surgery facility if he or she satisfies 1 of the following criteria:

(a)the patient is to receive day only Band 1, 2, 3, or 4 services (excluding uncertified Type C professional attention procedures) as specified in the Day Only Procedures Manual;

(b)the patient is to receive a Type C professional attention procedure as specified in the Day Only Procedures Manual and there is an accompanying certification by a medical practitioner that an admission is necessary on the grounds of the medical condition of the patient or other special circumstances relating to the patient;

(c)the patient, following a clinical decision, is expected to require overnight treatment for a minimum of 1 night;

(d)the patient is to receive a Type B professional attention procedure as specified in the Day Only Procedures Manual and there is an accompanying certification by a medical practitioner that an overnight admission is necessary on the grounds of the medical condition of the patient or other special circumstances relating to the patient.

Part 2—Private hospital services

2—Rehabilitation, psychiatric and pain assessment or management services by a private hospital

The charges for the provision to a patient by a private hospital of the rehabilitation, psychiatric and pain assessment or management services specified in Table 1 are as specified in that table.

3—Other private hospital services

(1)Subject to clause 2, the charges for the provision to an admitted patient by a private hospital of the services specified in columns 1 and 2 of Table 2 are as determined in accordance with this clause.

(2)Subject to subclause (5), the maximum charge for a service identified in columns 1 and 2 of Table 2 for an inlier patient is the Schedule Charge specified in column 3 of the table corresponding to that service.

(3)Subject to subclause (5), the maximum charge for a service identified in columns 1 and 2 of Table 2 for a short stay outlier patient is the charge calculated as follows:

Maximum Charge = Rate per Day × LOS

where—

(a)the Rate per Day is the rate per day specified in column 6 of the table corresponding to the service; and

(b)LOS is the length of stay of the patient in the hospital.

(4)Subject to subclause (5), the maximum charge for a service identified in columns 1 and 2 of Table 2 for a long stay outlier patient is the charge calculated as follows:

Maximum Charge = Schedule Charge + (Rate per Day × (LOS – Upper Trim Point))

where—

(a)the Schedule Charge is the charge specified in column 3 of the table corresponding to the service; and

(b)the Rate per Day is the rate per day specified in column 6 of the table corresponding to the service; and

(c)LOS is the length of stay of the patient in the hospital; and

(d)the Upper Trim Point is the Upper Trim Point specified in column 4 of the table corresponding to the service.

(5)Where the patient is transferred from the private hospital to another hospital, the maximum charge for the service provided by the transferring hospital is 80% of the charge determined in accordance with subclause (2), (3) or (4).

Part 3—Day surgery facility services

4—Day surgery facility services

The charges for the provision to an admitted patient by a day surgery facility of same day services included in Table 3 are the accommodation and theatre charges determined in accordance with the table.

Part 4—Tables

Table 1
Item No	Service description	Maximum charge (excl GST)
A charge applicable to an admitted patient is not payable unless the patient is admitted in accordance with the criteria for admission (see clause 1(5)). Private rooms are allocated on the basis of clinical need and the cost of such rooms is, unless otherwise stated, included in the per day charges specified. Where a patient requests a private room, WorkCover will not be responsible for or accept any surcharge. In this table— length of stay, in relation to an inpatient in a private hospital, means the number of days between the day of admission of the patient to the hospital and the day of discharge of the patient from the hospital—     (a)    counting the day of admission as 1 day (unless it is also the day of discharge); and     (b)    excluding the day of discharge.
HOSPITAL REHABILITATION SERVICES
Rehabilitation orthopaedic program for inpatients An orthopaedic program involves referral and assessment by the rehabilitation coordinator of the program. It is a defined program with intense service provision. Rapid improvement is expected and there are specific outcome goals. The program includes physiotherapy, aquatic therapy, occupational therapy, case conferences and discharge planning.
PR600	Length of stay 1 or more days but not more than 21 days	$485.30 per day
PR605	22 or more days	$406.80 per day
Rehabilitation trauma program for inpatients A trauma program involves referral and assessment by the rehabilitation coordinator of the program. It is a defined program with intense service provision. Rapid improvement is expected and there are specific outcome goals. The program includes physiotherapy, aquatic therapy, occupational therapy, speech therapy, case conferences and discharge planning.
PR610	Length of stay 1 or more days but not more than 50 days	$578.70 per day
PR615	51 or more days	$522.30 per day
PSYCHIATRIC SERVICES
Inpatient services
PR800	Length of stay 1 or more days but not more than 14 days	$495.30 per day
PR803	15 or more days	$381.10 per day
PR822	Electro‑convulsive therapy (ECT)	$212.00 per day
PR850	Private room allocated on basis of clinical need	$12.45 per day (additional charge)
Drug and alcohol program for inpatients This program provides specialised treatment and care for patients with alcohol or drug dependencies (including analgesics/narcotics/opiates and Benzodiazepine). The program is managed by a multi‑disciplinary team including a Medical Director and consultant psychiatrists. Where required, the program involves a medically controlled, safe withdrawal of drugs or alcohol.
PR990	Length of stay 1 or more days but not more than 14 days	$527.80 per day
PR991	15 or more days	$386.20 per day
Same day psychiatric services A day program is usually available to provide ongoing support and care to patients after discharge from treatment as inpatients. It is managed by a multi‑disciplinary team of health care professionals, and is tailored to the individual needs of the patient. It can include specialised therapy modules including cognitive behavioural therapy, relaxation, assertiveness skills and anxiety management. Outreach is treatment or care provided by the hospital to a non‑admitted patient at a location outside the hospital premises (being treatment or care provided as a direct substitute for treatment or care that would normally be provided on the hospital premises). For billing purposes, the 'O' in item numbers for same day services is an alphabetical letter not the number zero.
PRO81	Group session	$63.50
PRO82	Electro‑convulsive therapy day program	$331.00
PRO83	Half‑day program	$169.40
PRO84	Day program	$268.20
PRO95	Outreach	$153.00
OTHER SERVICES
Inpatient pain assessment/management
PR700	Length of stay 1 or more days but not more than 7 days	$425.80 per day
PR705	8 or more days but not more than 14 days	$400.00 per day
PR710	15 or more days	$260.00 per day

Table 3
Item No	Service description	Maximum charge (excl GST)
A charge applicable to an admitted patient is not payable unless the patient is admitted in accordance with the criteria for admission (see clause 1(5)). SAME DAY SERVICES FOR DAY SURGERY FACILITIES
Accommodation The band into which services fall will be determined in accordance with the Day Only Procedures Manual.
PR410	Band 1: including gastrointestinal endoscopy, some minor surgical and non‑surgical procedures not normally requiring anaesthetic.	$270.50
PR420	Band 2: procedures other than Band 1 performed under local anaesthetic with no sedation. Theatre time less than 1 hour.	$322.05
PR430	Band 3: procedures other than Band 1 performed under general or regional anaesthesia or intravenous sedation. Theatre time less than 1 hour.	$376.30
PR440	Band 4: procedures other than Band 1 performed under general or regional anaesthesia or intravenous sedation. Theatre time 1 hour or more.	$398.90
Theatre The band into which services fall will be determined in accordance with the Group Accommodation and Theatre Banding Schedule produced by the Commonwealth Department of Veterans' Affairs, November 2007. Where more than 1 service is provided in a single theatre session, the theatre charge is—     (a)    the theatre charge for the service with the highest theatre charge; plus     (b)    50% of the theatre charge for the service with the next highest theatre charge; plus     (c)     30% of the theatre charge for each of the other services so provided.
PRT1A	Band 1A	$155.40
PRT01	Band 1	$310.75
PRT02	Band 2	$396.65
PRT03	Band 3	$551.45
PRT04	Band 4	$797.80
PRT05	Band 5	$1 023.80
PRT06	Band 6	$1 348.10
PRT07	Band 7	$1 844.15
PRT08	Band 8	$1 968.45
PRT9A	Band 9A	$2 289.40
PRT09	Band 9	$2 626.10
PRT10	Band 10	$3 437.45
PRT11	Band 11	$4 878.20
PRT12	Band 12	$5 237.55
PRT13	Band 13	$4 952.80
PRT50	Dental minor	$293.80
PRT55	Dental major	$529.95

Note—

As required by section 10AA(2) of the Subordinate Legislation Act 1978, the Minister has certified that, in the Minister's opinion, it is necessary or appropriate that these regulations come into operation as set out in these regulations.

Made by the Governor's Deputy

following consultation as required under section 32(13) of the Workers Rehabilitation and Compensation Act 1986 and with the advice and consent of the Executive Council

on 7 February 2008

No 13 of 2008

07WKC0008CS