Information for General Practitioners FACT SHEET No.7

Payment of accounts and fees

Executive summary

The medical expenses of an injured employee will not normally be paid by Comcare until liability for a claim has been accepted. Until liability is accepted, each employee is responsible for their accounts.

Once a claim is accepted, medical accounts are normally paid within 30 days. Comcare generally uses the AMA Schedule of Fees or WorkCover rates as the upper limit of what can be paid.

Before liability has been determined

Claims managers will not usually pay the medical expenses of an employee until it has been decided that liability for the claim should be accepted. Employees are responsible for their own accounts until a claim has been accepted. Before a decision on liability has been made the treating doctor may choose to either give the account to the employee, who can arrange payment, or forward the account to the employee’s employer or workers’ compensation insurer.

Once a decision to accept liability is made, the account will normally be paid promptly. On average, Comcare issues payment approximately 30 days after receipt of an invoice. Comcare generally uses the AMA Schedule of Fees or WorkCover rates as the upper limit of what can be paid. Other insurers follow a similar approach.

While most accounts will not be paid until the claims manager decides that liability should be accepted, the exception to this can be medical reports. If a claims manager has requested a medical report to help to determine liability for a claim, payment for the report will be made regardless of whether the decision is made to accept the claim or not. But it should not be assumed that a claims manager will pay for a report that has been requested by another party, for example either the employee or an agent acting on behalf of the employee, such as a solicitor. In such circumstances it is advisable for the treating doctor to clearly establish who will pay for the report before it is prepared.

When a decision on liability is made

The employee will be advised when their claim has been accepted or rejected.

If the claim is accepted, then medical accounts for which liability is also accepted will be paid. (In some cases, not all of the conditions for which an employee has claimed will be accepted as work related). If the employee has paid the account, they will be reimbursed at this time. However, if the employee has not paid the account then the relevant treating practitioner or other service provider will be paid direct by the employer’s insurer. This may be Comcare or the claimant’s employer, if the employer holds a licence to self-insure.

If a claim is rejected, then the accounts will be given back to the employee who will need to make arrangements for their payment.

When the effects of the injury or disease have ceased

In most cases, the effects of the injury or disease will not continue indefinitely. In some cases, liability may be accepted for a specified period of time and may then be subject to review. In other cases, liability may continue for an extended period before it is decided that the effects of the condition have ceased.

In all cases, the employee will be advised of the situation and given an opportunity to present more evidence in favour of extending the duration of their claim if this is in question. Where it has been decided that an entitlement to compensation has ceased, any accounts relating to treatment after the date of cessation will be returned to the employee for their attention.

Page last updated:November 14, 2007