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Understanding the TAC fee structure
1 December 2016
Treating injured patients is a regular part of a physiotherapist’s working life: the patient books in for treatment, which is paid under the private fee scheme for initial and ongoing consultations.
However, when patients are injured in traffic accidents the practitioner will need to navigate some administrative lines when seeking full payment fees from the
Transport Accident Commission (TAC)
compensation scheme. A similar approach needs to be followed when also treating compensable patients injured in workplace accidents, says principal lawyer Malcolm Cumming from
Maurice Blackburn Lawyers
But it’s not a national standard, as the administrative process of treating compensable patients varies between states and territories and there can be further variation within jurisdictions.
The TAC administers the Victorian road accident compensation system and offers set reimbursement rates to victims of road accidents seeking treatment from a range of medical practitioners. Fees refunded by the TAC for treatment are lower than that charged to private patients. However, Victorian practitioners can successfully navigate the scheme and receive a full practice fee from the TAC by understanding the process of administration, Malcolm says.
‘Physiotherapists treating compensable patients under any compensation scheme need to understand that by doing so, they can be signing up their practice for additional administrative and time burdens to those usually incurred in the running of a physiotherapy practice,’ he says. ‘The TAC’s obligations at law, with respect to the funding of transport accident-related physiotherapy treatment, are in direct contrast with the low rates the TAC seeks to pay for such treatment. So, when invoicing the TAC for services they will need to apply for a higher fee reimbursement and not what it lists in its literature as the maximum amount possible.’
According to Section 60 of the Transport Accident Act 1986, the TAC must ‘fund the reasonable cost of services provided by a physiotherapist to people injured in transport accidents’. The maximum fees payable as a matter of course by the TAC are outlined in the
TAC Reimbursement Rates for Medical Services
guide, which, Malcolm says, ‘are considerably lower than the market rate’.
A comparison of TAC service fees with the market rate for physiotherapy treatment in private practice in Victoria shows a variation of about 20 per cent for an initial consultation and about 25 per cent for a standard consultation, as outlined in Table 1.
On submitting an invoice for treatment to the TAC, its standard response will be to only pay at the TAC schedule rate, Malcolm says.
‘The TAC will often assert it is only able to pay at the schedule rate, giving the impression of a legislative prohibition on paying the full reasonable cost. There is no such prohibition—the legislative requirement is to pay the full reasonable cost.’
To ensure patients are not out of pocket, practitioners need to understand patient rights to accessing full compensation, Malcolm adds. The
TAC No Fault Dispute Resolution Protocols
enables TAC clients with legal representation to challenge decisions.
Malcolm describes the process as ‘user-friendly’ as the process does not require a patient or practitioner to attend or pay for a conciliation meeting.
‘The TAC is invited to change its decision, and, if it doesn’t, then its representative and the client’s lawyer have a telephone conference and, irrespective of outcome, there are no legal costs, as these are payable by the TAC pursuant to the Protocols,’ he says. ‘The good news is a practitioner ought to only have to go through the process once, as it can stand for ongoing treatment for that patient, and set a benchmark for the treatment of others.
‘When challenged under the Protocols, the TAC has accepted liability for the cost of standard consultations in excess of $100 on the basis these are reasonable costs, within market range.’
Similarly, Maurice Blackburn lawyers, acting on behalf of a person injured in a workplace accident, recently lodged a successful challenge to payment of schedule fees by a WorkCover insurer by issuing proceedings in the Magistrates Court. As a result, the insurer paid the full amount of the ‘gap’ fees.
Despite success from challenges, Malcolm says the initial setting of lower TAC and WorkCover rates could have wider implications for patients seeking medical treatment, because:
physiotherapy clinics may not take on patients who are compensable-funded because it is cost and time prohibitive
clinics that treat patients (at TAC rates) will allocate treatment to junior rather than experienced practitioners
clinics will introduce ‘gap payments’ representing the difference between the schedule rates and standard private practice rates.
‘With the latter, some TAC patients may not be able to afford to pay a gap fee, particularly on an ongoing basis,’ Malcolm says, adding that while dispute resolution is a standard process, setting ‘reasonable fees by the TAC’ would mitigate the need for patients to apply for a review.
‘The law says it will only pay “reasonable costs”, so the TAC tends to give the impression to practitioners that the advertised TAC Reimbursement Rates are the maximum amounts payable, but they don’t reflect the market rate and, therefore, the TAC is not meeting its statutory obligations,’ Malcolm says.
‘Physiotherapists are entitled at law to charge compensable patients at the same rate they charge private patients.
‘Running a practice is busy enough without the added burden of worrying about this. Private practice fees in Victoria already lag behind those paid in other states. So, there should be a reasonable standard reimbursement figure set with adequate provision built in so fees can vary.’
The TAC fee table can be found at:
Understanding the TAC fee structure
Treating patients injured in a traffic accident should not mean patient or practitioner is left out of pocket.
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Pat Cosh Trust Fund grants 2017