Document name

Health Care Services

Document number

PRO 18/2016

The Workers’ Compensation Board (WCB) has approved POL 18/2016, Health Care Services which provides guidelines for the payment and authorization of health care paid for, or reimbursed by the WCB.

1. The WCB supports the functional rehabilitation model, which allows for assessment and treatment of the injured worker to be delivered at three levels –Level I (primary), Level II (secondary), and Level III (tertiary) – in accordance with POL 08/2014, Continuum of Care. This model recognizes the importance of returning the injured worker to functional activities relevant to their life, including returning to work, during the recovery period, even where some discomfort may arise.

Responsibilities

2. Jointly with the health sector, the WCB will:
   1. Establish practice standards for health care provider groups and health care facilities providing care to WCB customers.
   2. Support a continuum of care model, in accordance with POL 08/2014, Continuum of Care, which facilitates quality health care and an appropriate return to work.
   3. Where necessary, assist the primary health care provider in accessing the earliest available specialist and diagnostic appointments.
   4. Ensure there are an adequate number of WCB accredited rehabilitation centres throughout the province, and
   5. Offer expedited service agreements to health care provider groups with longer wait times in order to promote early recovery and return-to-work by increasing capacity in the health care system, rather than eliminating public service time. In general, the WCB will consider longer wait times to be:
      1. Greater than four to six weeks for specialists.
      2. Greater than three weeks for most diagnostics, or
      3. Greater than two months for surgery.
3. WCB Health Care and Medical Consultants are a resource and support service to both WCB staff and health care providers.
4. Health care providers who treat WCB customers are required to:
   1. Report all work injuries.
   2. Help injured workers or dependents apply for compensation.
   3. Invoice the WCB, and not the worker, in order to prevent any financial inconvenience to the worker.
   4. Avoid extra billing by adhering to the fee schedule approved by the WCB or the Saskatchewan Ministry of Health.
   5. Avoid billing for services that are medically unnecessary.
   6. Treat all health-related and personal information gathered during the course of treatment of a WCB customer in a confidential manner.
   7. Advise the worker and employer of any work restrictions, as well as a projected date of recovery as soon as possible after the injury occurs.
   8. Help an early return to work (POL 08/96, Return-to-Work Plans).
   9. Meet the reporting and continued education requirements set out in their discipline’s agreement with the WCB.
   10. Request advanced assessment and treatment where required, and
   11. Work collaboratively with other health care providers involved in the worker’s care.
5. The following health care providers are pre-authorized to treat WCB customers:
   1. Health care providers funded by the Saskatchewan Ministry of Health.
   2. Physicians licensed in North America.

If a claim is denied after treatment has already been provided, the WCB will pay the appropriate WCB approved fee.

6. Health care providers established on a negative response system are authorized to  provide a limited number of treatments  prior to the WCB replying to an initial assessment report.
7. All other health care providers not included under Point 5 or 6 will be required to receive a signed primary Authorization to Treat form from the WCB before commencing treatment. Where this authorization is not received prior to treatment, services provided will not be paid for by the WCB.
8. To prevent an actual or potential conflict of interest and to allow workers to make an informed decision regarding consultation, assessment or treatment at a facility, health care providers must disclose to workers any business relationship with the injured worker’s employer.

Payment of Medical Treatment

9. Payment for treatment will be provided to health care providers who:
   1. Are physicians licensed to practice in North America.
   2. Are accredited and funded by the Saskatchewan Ministry of Health, or
   3. Appear on the WCB approved provider list.
10. Other health care providers who are not on the WCB approved provider list, and wish to be recognized by the WCB, must apply for accreditation, providing the necessary information (i.e., credentials, license with professional organization, description of evidence-based practice, etc.).
11. If a health care provider association does not wish to participate in the accreditation process, the WCB may establish accreditation standards, applicable only to services provided to WCB customers, using the expertise of WCB’s Medical and Health Care Services.
12. The WCB may approve payment to an unaccredited health care provider that offers infrequent service to WCB customers (e.g., naturopaths or orthotists). Prior to approving any such treatment, the WCB will perform a review to ensure the unaccredited health care provider is registered with a national or provincial representative professional organization and that any proposed treatment(s) are evidenced based.
13. To expedite treatment, the WCB may approve health care outside of the injured worker’s home community. POL 04/2021, Travel Expenses - General, will apply.
14. Out-of-province and out-of-country treatment (i.e., services outside of the worker’s resident province or Canada) will be considered by the WCB where the primary health care provider or specialist’s referral is for evidence-based practice. Approval will be granted where the services are not available in the resident province or Canada within appropriate timelines.
15. Operations staff will request that WCB’s Health Care Services (HCS) review out-of-province health care providers to ensure they meet the accreditation standards of:
    1. The Saskatchewan Ministry of Health.
    2. Another jurisdiction's Ministry of Health, or
    3. The Saskatchewan WCB.
16. Prescription and non-prescription drugs will be considered health care if they are conducive to treating the work injury. POL 11/2019, Medication Coverage, applies.
17. The WCB Operations staff will monitor a claim’s progress and may cease payment for health care where:
    1. There are no functional gains being made.
    2. There are indications that the customer has functionally recovered from the work injury, or
    3. The health care provider fails to maintain accreditation credentials or provide the required reports.
18. If a care provider group does not require pre-authorization to treat or has a negative response agreement with the WCB, and a worker’s claim is subsequently denied, the WCB will notify the health care provider accordingly and will be responsible for payment of services up to the date of notification of disallowance. With the exception of Point 5, payment is dependent on the health care provider having obtained WCB authorization for treatment and payment prior to providing care.

Alternative Treatment and Equipment

19. The WCB does not generally approve payment for non-standard, not generally accepted or experimental treatment or equipment. Proposals for alternative or innovative treatments must be approved by HCS.
20. Alternative treatment or equipment may be approved by HCS where:
    1. The treatment is to be provided by a health care provider accredited by:
       1. The Saskatchewan Ministry of Health.
       2. Another jurisdiction’s Ministry of Health, or
       3. The WCB, and
    2. There is a recommended level of research and clinical evidence supporting the effectiveness of the treatment or equipment as determined by WCB’s Medical and Health Care Services medical consultants using the Best Evidence Synthesis Model.
21. Appliances not included in a WCB fee schedule will be funded on a case-by-case basis. Medical and Health Care Services will assist in evaluating an appliance’s effectiveness. Where no endorsed fee exists in a WCB medical fees procedure, a fee considered reasonable by the Operations staff, in consultation with Medical and Health Care Services, will be applied.