All about WorkCover shoulder surgery

Whether surgery is approved will depend on your individual circumstances, the medical evidence supporting the procedure, and whether the insurer accepts that the surgery is reasonably required as a result of your work injury.

This guide explains how to apply for WorkCover shoulder surgery, what happens if the insurer approves or rejects the request, and how shoulder surgery may affect other aspects of your WorkCover compensation claim.

How do I apply for WorkCover shoulder surgery?

Before undergoing surgery, it is important to obtain approval from the WorkCover insurer.

Generally, your treating specialist surgeon will submit a written request to the insurer outlining:

• Your shoulder condition.
• The proposed surgery.
• Why the procedure is medically required.
• The expected benefits of the surgery.

The insurer will then consider the application.

In some cases, the insurer may approve the surgery based on the medical information already available. However, it is common for the insurer to arrange an Independent Medical Examination (IME) before making a decision.

The independent medical examiner will usually be asked to provide an opinion about:

• Whether surgery is appropriate.
• Whether the need for surgery relates to the work injury.
• Whether other treatment options should be explored first.

Unfortunately, arranging and attending an IME can sometimes delay treatment and the insurer’s decision-making process.

What happens if WorkCover approves shoulder surgery?

If the insurer approves the surgery, you should receive written confirmation of the decision. Your WorkCover claims manager may also contact you directly.

Following approval, you can work with your surgeon to arrange the procedure.

Who pays for the surgery?

Where surgery is approved, the WorkCover insurer is generally responsible for paying:

• The approved surgical costs.
• Hospital costs associated with the procedure.
• Follow-up consultations.
• Physiotherapy and rehabilitation related to the operation.
• Other reasonable medical and like expenses arising from the surgery.

Will WorkCover pay the full cost?

WorkCover pays medical providers according to fixed fee schedules. For this reason, it is important to discuss costs with your surgeon before undergoing the procedure.

You should ask:

• Whether the surgeon charges above WorkCover rates.
• Whether there will be any out-of-pocket expenses.
• Whether all costs are expected to be covered by WorkCover.

Many surgeons who regularly perform WorkCover shoulder surgery limit their fees to the amounts paid by WorkCover so that injured workers do not incur additional costs.

Travel expenses

WorkCover may also pay reasonable travel expenses associated with medical treatment.

This can be particularly important for injured workers living in regional Victoria who need to travel significant distances to attend appointments with shoulder specialists.

What are the WorkCover payment rates for shoulder surgery?

WorkCover generally pays approved surgical procedures according to set fee schedules rather than whatever a provider chooses to charge.

The amount payable depends on factors such as:

• The type of shoulder surgery being performed.
• The surgeon’s item numbers.
• Hospital and theatre costs.
• Associated treatment and rehabilitation expenses.

Because payment rates vary between procedures, workers should always confirm with both their surgeon and the WorkCover insurer whether there are likely to be any out-of-pocket expenses before proceeding with surgery.

What happens if WorkCover rejects shoulder surgery?

If the insurer refuses to pay for the surgery, it should provide written reasons for the decision.

There are several reasons why a WorkCover shoulder surgery request may be rejected.

The IME disagrees with the surgeon

A common reason for refusal is that the independent medical examiner does not agree with the treating specialist’s recommendation.

For example, the IME may believe:

• Surgery is not required.
• A different surgical procedure is more appropriate.
• Conservative treatment should be tried first.

The surgery is not considered related to the work injury

The insurer may argue that the need for surgery arises from:

• A pre-existing shoulder condition.
• Age-related degeneration.
• A condition unrelated to the workplace injury.

Further treatment should be tried first

An IME may recommend that you first undergo additional conservative treatment, such as:

• Physiotherapy.
• Exercise rehabilitation.
• Ultrasound-guided cortisone injections.

Can I challenge the decision?

Yes.

If you disagree with the insurer’s decision, one of the first steps is often to commence the conciliation process.

Conciliation provides an opportunity to challenge the insurer’s decision and attempt to resolve the dispute without court proceedings.

If the dispute is not resolved at conciliation, further options may be available depending on your circumstances.

How does shoulder surgery affect my WorkCover claim?

Medical and like expenses

If surgery is approved, the WorkCover insurer should pay the reasonable costs of the surgery together with related rehabilitation and treatment expenses.

Weekly payments

If you are unable to work because of the surgery or recovery period, you may be entitled to receive weekly payments, provided you otherwise remain eligible.

Need advice about WorkCover shoulder surgery?

If your WorkCover shoulder surgery has been refused, delayed, or you are unsure about your rights, obtaining legal advice can help you understand your options and whether the insurer’s decision can be challenged.