GOV-045270
Health Services Provider Remedies Framework
OWNER
Manager Health Sector Engagement & Performance
Manager Recovery Services
DATE APPROVED
16 September 2025
APPROVER
Deputy Chief Executive – System Commissioning & Performance
DATE OF NEXT
30 June 2026
REVIEW
1. Purpose
This framework sets out ACC’s approach to investigating concerns about a health services
provider’s conduct (including compliance with contracts for services), competence or health,
together with the principles ACC will consider when deciding what remedies (if any) are
required.
The Health Services Provider Remedies Framework – Operational Guidelines support this
framework and provide further guidance on how health services provider issues are assessed,
explored, enquired and resolved.
2. Background
ACC pays health services providers for providing treatment to ACC clients.
2.1 Contract for services providers
Payments are made to some health services providers through contracts for services between
the health services provider and ACC. For example, rural GPs are covered under contracts for
services.
ACC’s contracts for services include mechanisms for improving service performance.
2.2 Cost of Treatment Regulations providers
Most health services providers that do not have a contract with ACC are paid a standard rate
(dependent on the service provided). These rates are specified in the Accident Compensation
(Liability to Pay or Contribute to Cost of Treatment) Regulations 2003 (
Cost of Treatment
Regulations).
ACC is not required to pay health services providers under the Cost of Treatment Regulations
unless it is satisfied that the treatment is necessary, appropriate and of the quality required for
the purpose (amongst other requirements). However, this applies on an individual claim level
and cannot be used as a mechanism to improve service performance.
ACC’s expectations for Cost of Treatment Regulations providers are set out on ACC’s website
(see the Understanding your responsibilities page).
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2.3 Pre-approved treatment providers
Some health services providers that do not have a contract with ACC are not covered by the
Cost of Treatment Regulations (for example, Rongoā Māori services providers). These
providers are paid a pre-approved rate (dependent on the service provided).
ACC is not required to pay pre-approved treatment providers unless it is satisfied that the
treatment is necessary, appropriate and of the quality required for the purpose (amongst other
requirements). However, this applies on an individual claim level and cannot be used as a
mechanism to improve service performance.
ACC’s expectations for pre-approved treatment providers are set out on ACC’s website (see
the Understanding your responsibilities page).
2.4 Responsible authorities
Many of ACC’s health services providers are covered by the Health Practitioners Competence
Assurance Act 2003, which regulates responsible authorities (for example, physiotherapists
have the Physiotherapy Board).
ACC’s health services providers that are not covered by the Health Practitioners Competence
Assurance Act 2003 include counsellors, social workers and Rongoā Māori services providers.
Some of these providers will also have responsible bodies (for example, social workers have
the Social Worker Registration Board).
3. Business as usual
3.1 Engagement & Performance Managers and Performance Monitoring Advisors
Engagement & Performance Managers and Performance Monitoring Advisors are responsible
for ACC’s business as usual engagement with health services providers. In particular, they
deal with day-to-day conduct, competence or health issues (i.e. issues that are not material
enough to require consideration under the provider remedies process set out below).
Authority
An Engagement & Performance Manager or Performance Monitoring Advisor has authority to
decide the appropriate remedies in respect of:
(a) conduct, competence or health issues that have been assessed as low risk; and
(b) cases of overbil ing where the total amount of the overbilling is up to $5,000.
The Manager Fraud Prevention & Investigation must be consulted when the matter relates to
potential fraud or other criminal issue.
Remedies
An Engagement & Performance Manager or Performance Monitoring Advisor will consider the
matters referred to them. If he/she determines that the health services provider’s conduct,
competence or health is inadequate and a remedy is required, he/she may impose any of the
following remedies:
(a) letter of expectations;
(b) refuse payment of costs of treatment;
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(c) performance improvement plan; and
(d) repayment plan.
3.2 Escalation
Where an Engagement & Performance Manager or Performance Monitoring Advisor
determines that the matter requires a remedy outside their authority, he/she may escalate the
matter to the:
(a) Team Manager Engagement & Performance;
(b) Provider Monitoring Manager;
(c) Provider Issues Management Group;
(d) Provider Risk of Harm Group;
(e) Manager Health Sector Engagement & Performance; or
(f) Manager Recovery Services.
4. Provider remedies process
Stage 1 – assess
Upon identifying a concern in respect of a health services provider’s conduct, competence or
health, ACC will assess whether it is reasonable and within ACC’s remit to deal with.
Where ACC is not the appropriate entity to address the matter, it may refer the matter to
another entity.
At this stage, ACC will undertake a risk assessment in respect of the matter. This allows it to
identify any matters that may require immediate attention.
Stage 2 – explore
ACC will gather information to understand the full extent of the possible conduct, competence
or health issue.
Stage 3 – enquire
ACC will decide whether the matter, and any information that has been gathered about it,
shows that the health services provider’s conduct, competence or health is inadequate.
Stage 4 – resolve
The table in Appendix 1 sets out the who has authority in respect of conduct, competence or
health issues.
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4.1 Team Manager Engagement & Performance and Provider Monitoring Manager
Authority
A Team Manager Engagement & Performance or Provider Monitoring Manager has authority
to decide the appropriate remedies in respect of:
(a) conduct, competence or health issues that have been assessed as low risk; and
(b) cases of overbil ing where the total amount of the overbilling is up to $25,000.
The Manager Fraud Prevention & Investigation must be consulted when the matter relates to
potential fraud or other criminal issue.
Remedies
A Team Manager Engagement & Performance or Provider Monitoring Manager will consider
the matters referred to them. If he/she determines that the health services provider’s conduct,
competence or health is inadequate and a remedy is required, he/she may impose any of the
following remedies:
(a) letter of expectations;
(b) refuse payment of costs of treatment;
(c) performance improvement plan;
(d) repayment plan; and
(e) contract suspension.
Escalation
Where a Team Manager Engagement & Performance or Provider Monitoring Manager
determines that the matter requires a remedy outside their authority, he/she may escalate the
matter to the:
(a) Provider Issues Management Group;
(b) Provider Risk of Harm Group;
(c) Manager Health Sector Engagement & Performance; or
(d) Manager Recovery Services.
4.2 Provider Issues Management Group
The Provider Issues Management Group is an ACC decision-making group with responsibility
for considering health services provider issues that do not pose a risk of harm to the public.
The Provider Issues Management Group – Terms of Reference sets out the group’s purpose,
decision-making authority, responsibilities and membership.
Authority
The Provider Issues Management Group has authority to consider:
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(a) conduct, competence or health issues that have been assessed as medium or high risk;
and
(b) cases of overbil ing where the total amount of the overbilling is up to $100,000 (cases over
$100,000 should be referred to a Manager Health Sector Engagement & Performance or
the Manager Recovery Services).
The Provider Issues Management Group does not have authority in respect of issues that may
pose a risk of harm to the public.
The Manager Fraud Prevention & Investigation must be consulted when the matter relates to
potential fraud or other criminal issue.
Decisions made by the Provider Issues Management Group must be approved by a Manager
Health Sector Engagement & Performance or the Manager Recovery Services.
Remedies
The Provider Issues Management Group will consider the matters referred to it. If the group
determines that the health services provider’s conduct, competence or health is inadequate
and a remedy is required, it may impose any of the following remedies:
(a) letter of expectations;
(b) refuse payment of costs of treatment;
(c) performance improvement plan;
(d) repayment plan;
(e) contract suspension;
(f) contract termination; and
(g) civil litigation.
Imposing the fol owing remedies must also be approved by a person with delegated authority
under the Corporate Delegations Policy:
(a) contract termination; and
(b) civil litigation.
Escalation
Where the Provider Issues Management Group determines that the matter requires a remedy
outside its authority, it may escalate the matter to a Manager Health Sector Engagement &
Performance or the Manager Recovery Services.
4.3 Provider Risk of Harm Group
The Provider Risk of Harm Group is an ACC decision-making group with responsibility for
considering health services provider issues that may pose a risk of harm to the public.
The Provider Risk of Harm Group – Terms of Reference sets out the group’s purpose,
decision-making authority, responsibilities and membership.
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Authority
The Provider Risk of Harm Group has authority to consider cases of conduct, competence or
health issues that may pose a risk of harm to the public.
The Provider Risk of Harm Group does not consider cases where a health services provider
(including a person who is not a registered health professional) provides treatment that causes
a personal injury. These cases are considered by the Treatment Injury Risk of Harm Review
Group.
Decisions made by the Provider Risk of Harm Group must be approved by the Chief Clinical
Officer or a Manager Health Sector Engagement & Performance or the Manager Recovery
Services.
Remedies
The Provider Risk of Harm Group will consider the matters referred to it. If the group
determines that the health services provider’s conduct, competence or health is inadequate
and a remedy is required, it may impose any of the following remedies:
(a) letter of expectations;
(b) refuse payment of costs of treatment;
(c) performance improvement plan;
(d) contract suspension;
(e) contract termination;
(f) notification to responsible authority or Health and Disability Commissioner;
(g) repayment plan; and
(h) civil litigation.
Imposing the fol owing remedies must also be approved by a person with delegated authority
under the Corporate Delegations Policy:
(a) contract termination; and
(b) civil litigation.
Escalation
Where the Provider Risk of Harm Group determines that the matter requires a remedy outside
its authority, it may escalate the matter to a Manager Health Sector Engagement &
Performance or the Manager Recovery Services.
4.4 Manager Health Sector Engagement & Performance or Manager Recovery Services
Authority
A Manager Health Sector Engagement & Performance or the Manager Recovery Services (or
their delegate) has authority to consider all conduct, competence or health issues.
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The Manager Fraud Prevention & Investigation must be consulted when the matter relates to
potential fraud or other criminal issue.
Remedies
A Manager Health Sector Engagement & Performance or the Manager Recovery Services (or
their delegate) may impose any of the following remedies:
(a) letter of expectations;
(b) refuse payment of costs of treatment;
(c) performance improvement plan;
(d) repayment plan;
(e) contract suspension;
(f) contract termination;
(g) civil litigation; and
(h) notification to responsible authority or Health and Disability Commissioner.
A Manager Health Sector Engagement & Performance or the Manager Recovery Services (or
their delegate) may, fol owing a Fraud Prevention & Investigation team investigation, refer
provider issues involving suspected fraud or other criminal activity to the Prosecution Panel for
consideration of the following remedies:
(a) notification to law enforcement for intended prosecution; and
(b) ACC-led prosecution.
The Prosecution Panel’s purpose is to ensure fair, proportionate and consistent decision-
making by providing recommendations on prosecution and other remedies. It applies ACC’s
Prosecution Policy, Prosecution Procedure and Prosecution Guidelines. The Prosecution
Panel does not have delegated authority to make final decisions. Instead, it makes
recommendations to relevant decision-makers.
Imposing the fol owing remedies must also be approved by a person with delegated authority
under the Corporate Delegations Policy:
(a) contract termination;
(b) civil litigation;
(c) notification to law enforcement for intended prosecution; and
(d) ACC-led prosecution.
5. Assessment
5.1 Natural justice
When deciding whether a health services provider’s conduct, competence or health is
inadequate ACC must comply with the principles of natural justice.
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The principle of natural justice ensures that people subject to criticism or adverse findings
have a proper opportunity to respond to ensure that ACC’s decisions are fair and accurate.
If a proposed decision may adversely affect the interests of a health services provider, ACC
must be satisfied that the provider is aware of the matters on which the proposed decisions is
based and has had an opportunity, at any time in the course of the provider remedies process,
to respond on those matters.
ACC will then consider responses in light of further information provided and finalise its
decision.
5.2 Conduct, competence or health
The criteria ACC considers when deciding whether a health services provider’s conduct,
competence or health is inadequate includes:
(a) the actual or potential risk of harm to the public;
(b) whether the health services provider may have health condition that may present a risk to
their ability to practise safely or effectively;
(c) whether the matter may undermine public confidence in the accident compensation
scheme (
Scheme);
(d) in the case of health practitioners, whether the matter could amount to a breach of the
relevant responsible authority’s standards of conduct, performance and ethics, standards
of proficiency and other relevant guidance for practitioners;
(e) whether the matter is a serious concern of the type listed in section
8;
(f) whether the matter calls into doubt the health services provider’s honesty; and
(g) any other public interest considerations.
5.3 Remedy
In making decisions on remedy, ACC will strike a balance between the competing interests of
the health services provider and ACC’s overriding objective to protect clients and the Scheme.
Therefore, decisions will deal with the concern raised, but be fair, just and reasonable.
Remedies are not intended to be punitive. ACC will only take the minimum action necessary to
ensure clients and the Scheme are protected.
6. Mitigating factors
6.1 Overview
When considering the appropriate remedy, ACC will evaluate any mitigating factors. ACC must
therefore give due consideration to all the information available to it about the particular
matter, including any wider contextual factors. These considerations will then form part of
ACC’s wider balancing exercise to determine what action is necessary (if any).
Whilst mitigating factors do not excuse or justify poor conduct or competence, they may be
useful indicators of a reduced ongoing risk posed to clients and the Scheme. For this reason,
mitigating information may reduce the severity of the remedy required or, in some cases,
mean that a remedy is no longer required at all.
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A key factor in determining what, if any, remedy is appropriate is likely to be the extent to
which a health services provider recognises their failings and is willing to address them. Where
a health services provider does recognise their failings and is wil ing to address them, the risk
of repetition is reduced.
6.2 Insight and remorse
Where present, genuine insight and remorse can indicate that:
(a) the health services provider wil comply with any restrictions imposed by ACC;
(b) the risk of repetition, and therefore the risk to clients and the Scheme, is significantly lower
than cases where insight is not present; and
(c) the risk of damage to public confidence in the Scheme is reduced.
In taking account of any insight or remorse offered by a health services provider, ACC will be
mindful that there may be cultural differences in the way these might be expressed, both
verbally and non-verbally. This may be more pronounced where English is not the health
services provider’s first language.
Insight
Insight is a health services provider’s genuine understanding and acceptance of the concerns,
which have been raised in relation to their conduct, competence or health. It is likely to be
demonstrated by:
(a) a genuine recognition of the concerns raised;
(b) an understanding of the impact or potential impact of their actions; and
(c) demonstrable empathy for the client(s) involved (if applicable).
Remorse
Expressing remorse involves a health services provider taking responsibility and exhibiting
regret for their actions, and may be demonstrated by one or more of the following:
(a) acknowledging wrongdoing; and
(b) undertaking appropriate remediation.
6.3 Remediation
Remediation involves a health services provider taking steps to address any concerns that
have been raised about their conduct, competence or health. Successful remediation is likely
to:
(a) indicate the health services provider has insight into the deficiencies in their conduct,
competence or health;
(b) reduce the risk of repetition of the concerns; and
(c) reduce the risk to clients and the Scheme.
Whether or not remediation has been undertaken, and if any remediation can be considered
successful, are important aspects of ACC’s assessment of what risk the health services
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provider might pose to clients and the Scheme, and therefore what remedy, if any, is required
to mitigate that risk.
There are a wide range of remediation activities available to a health services provider, and
the form of that remediation wil depend upon the nature of the concerns raised. The decision
as to the appropriateness of the remediation is for ACC to make.
7. Aggravating factors
7.1 Overview
When considering the appropriate remedy, ACC will evaluate any aggravating factors.
Aggravating factors are any features of a matter which increase the seriousness of the matter.
Where present, they are likely to lead to stronger remedies in order to protect clients and the
Scheme.
As with mitigating factors, when considering the impact on remedy ACC will properly evaluate
these factors in the round and on a case-by-case basis. ACC must therefore give due
consideration to all the information available to it about that particular matter, including any
wider contextual factors. These considerations will then form part of ACC’s wider balancing
exercise to determine what action is necessary for public protection.
7.2 Breach of trust
Trust is a fundamental aspect of the relationship between a health services provider and a
client and between a health services provider and ACC. Breaching this trust can have
significant impacts on public protection. For example, a client may not engage with a health
services provider because they are concerned, they cannot trust them, delaying treatment.
Breaches of trust are of even greater seriousness where they involve a vulnerable client.
Where there has been a breach of trust, ACC is likely to impose more serious remedies.
7.3 Repetition of misconduct or unacceptable behaviour
A repetition of misconduct or unacceptable behaviour leads to greater potential risks to clients
and the Scheme, for a number of reasons such as:
(a) the fact the conduct or behaviour has been repeated increases the likelihood it may
happen again; and
(b) the repetition indicates the health services provider may lack insight.
Repeated misconduct or unacceptable behaviour, particularly where previously addressed by
ACC, is likely to require more serious remedies to address the risks outlined above.
7.4 Lack of insight or remorse
Where a health services provider lacks insight or fails to express remorse, they may pose a
higher risk to clients and the Scheme.
Health services providers who lack a genuine recognition of the concerns raised about their
conduct, competence or health, and fail to understand or take responsibility for the impact or
potential impact of their actions, are unlikely to address the concerns raised. For this reason,
in these cases ACC is likely to take more serious action in order to protect clients and the
Scheme.
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7.5 Lack of remediation
If a contract for services provider chooses not to undertake remediation activities to address
ACC’s concerns, or fails to remediate when they have promised to do so, it could indicate a
lack of insight. This might significantly increase the risk of repetition and therefore risk to
clients and the Scheme. It is therefore likely that cases involving little, or no remediation might
require more serious remedies to protect clients and the Scheme.
7.6 Harm to member of the public
In cases where a member of the public has been harmed, or there was potential for harm to be
caused, ACC will be particularly mindful of any ongoing risk to clients and the Scheme, and
any impact on public confidence in the Scheme.
Harm to a member of the public, or the potential for this, will be of particular importance in
cases involving vulnerable clients. In these cases, clients and the Scheme expect that more
serious action is taken to address concerns around conduct or behaviour.
8. Serious concerns
There are some matters which are so serious, that activities intended to remediate the matter
cannot sufficiently reduce the risk to clients and the Scheme. Notwithstanding the steps the
health services provider may take to attempt to remediate the matter, ACC is still likely to
impose a serious remedy. These might include cases involving:
(a) dishonesty;
(b) discrimination;
(c) abuse of professional position, including vulnerability;
(d) sexual misconduct;
(e) sexual abuse of children or indecent images of children;
(f) criminal convictions for serious offences; and
(g) violence.
9. Remedies
The table in Appendix 2 sets out the available remedies and who can impose them (including
the remedies available to Engagement & Performance Managers and Performance Monitoring
Advisors outside the remedies process set out in this framework). ACC can impose multiple
remedies in respect of the same health services provider (for example, notifying a responsible
authority and imposing a performance improvement plan that restricts the provider).
9.1 Feedback
It is unlikely that ACC wil take no action following a finding of inadequate conduct,
competence or health. However, there may be occasions where ACC considers providing
informal feedback to be the appropriate and proportionate outcome.
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9.2 Letter of expectations
A letter of expectations sets out ACC’s expectations for the health services provider and its
future conduct or performance. The letter may set out where a health services provider has
breached ACC’s requirements. The letter may also set out additional requirements that the
provider must comply with when invoicing ACC.
ACC may issue letters of expectation to contract for services providers, Cost of Treatment
Regulations providers and pre-approved treatment providers.
9.3 Refuse payment of costs of treatment
ACC is liable to pay the cost of the claimant’s treatment if the treatment is for the purpose of
restoring the claimant’s health to the maximum extent practicable, and the treatment:
(a) is necessary and appropriate, and of the quality required, for that purpose;
(b) has been, or will be, performed only on the number of occasions necessary for that
purpose;
(c) has been, or will be, given at a time or place appropriate for that purpose;
(d) is of a type normally provided by a health services provider; and
(e) is provided by a health services provider of a type who is qualified to provide that treatment
and who normally provides that treatment.
ACC may refuse to pay the costs of treatment where the criteria above are not satisfied.
Please note that ACC’s power to refuse to pay the costs of treatment applies on an individual
claim level and cannot be used to impose quality control mechanisms or limit the services of
providers.
9.4 Performance improvement plan
A performance improvement plan requires a health services provider to undertake certain
actions or restricts them in certain ways. In some cases it may be appropriate to impose a
single condition for a short period. However, in most cases, a combination of conditions will be
necessary.
A performance improvement plan can (amongst other requirements) require a health services
provider to undertake education/training or impose restrictions on the payment of a health
services provider’s invoices. The plan can also set out monitoring arrangements in respect of a
health services provider’s conduct, competence or health.
ACC may issue performance improvement plans to contract for services providers and may
agree plans with Cost of Treatment Regulations providers and pre-approved treatment
providers.
9.5 Repayment plan
A repayment plan requires a health services provider to repay amounts previously paid by
ACC to the health services provider because of overbilling. The health services provider must
agree to the repayment plan (i.e. ACC cannot require a health services provider to enter into a
repayment plan). The plan may also set out additional requirements that the provider must
comply with when invoicing ACC.
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ACC may agree repayment plans with contract for services providers, Cost of Treatment
Regulations providers and pre-approved treatment providers.
Writes offs of health services provider debts must be approved in accordance with the Case
and Claims Delegations Policy.
9.6 Suspension
ACC may not suspend Cost of Treatment Regulations providers or pre-approved treatment
providers from providing treatment to ACC clients.
ACC’s contracts for services allow ACC to suspend health services providers (including an
individual health services provider) from providing services to ACC clients.
ACC may give a health services provider written notice that al or any of the services under a
contract of services with ACC are suspended because ACC considers on reasonable grounds:
(a) that the health services provider may have breached the contract, and
(b) for any reason it is not appropriate for the health services provider to continue to provide
services (for example, while the issue is investigated).
9.7 Contract termination
If a contract for services provider has breached a provision of its contract for services with
ACC, ACC may give notice to the health services provider specifying the breach. The notice
must give the health services provider ten business days to stop or to remedy the breach (if it
is capable of remedy).
If the breach has not stopped or been remedied within ten business days, ACC may forward to
the health services provider a notice of termination of:
(a) the contract and all of the services being provided under the contract, or
(b) particular services being provided under the contract.
ACC may not stop Cost of Treatment Regulations providers or pre-approved treatment
providers from providing treatment to ACC clients.
Contract terminations must be approved by a person with delegated authority under the
Corporate Delegations Policy.
9.8 Civil litigation
If a contract for services provider breaches its contract for services with ACC, ACC may bring
civil litigation for breach of contract.
If a contract for services provider, Cost of Treatment Regulations provider or pre-approved
treatment provider engages in over bil ing, ACC may bring civil litigation for unjust enrichment.
The Collections & Recovery team is responsible for managing civil litigation to recover debt.
The Legal team is responsible for managing al other civil litigation.
Commencing civil litigation must be approved by a person with delegated authority under the
Corporate Delegations Policy.
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9.9 Notification to responsible authority or Health and Disability Commissioner
Every health practitioner who practises in a regulated profession in New Zealand must be
registered with the relevant responsible authority and hold an Annual Practising Certificate
(APC) issued by that authority.
The functions of each authority appointed in respect of a health profession include receiving
information from any person about the practice, conduct or competence of health practitioners
and, if it is appropriate to do so, act on that information.
ACC must notify a responsible authority in the ‘compulsory notification’ circumstances set out
in Appendix 3.
ACC may notify a responsible authority or the Health and Disability Commissioner in the
‘optional notification’ circumstances set out in Appendix 3.
Any notification by ACC in respect of a health services provider who is a health practitioner to
a responsible authority must be signed by a health practitioner employed by ACC (the health
practitioner signing the notification must agree with the decision to notify the responsible
authority i.e. ACC cannot require a health practitioner to sign a notification against their
wishes).
9.10 Notification to law enforcement for intended prosecution
Where a matter involves fraud or other criminal wrongdoing, ACC may notify the police or
other law enforcement for investigation.
Notification to law enforcement for intended prosecution must be approved by a person with
delegated authority under the Corporate Delegations Policy.
9.11 ACC-led prosecution
Where a matter involves fraud or other criminal wrongdoing, ACC may bring an ACC-led
prosecution under the Accident Compensation Act 2001 or Crimes Act 1961.
Commencing ACC-led prosecutions must be approved by a person with delegated authority
under the Corporate Delegations Policy and the Prosecution Policy, Prosecution Procedure
and Prosecution Guideline must be applied.
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10. Version control
Version
Date
Change reason
1.0
15 September 2024
Framework approved.
1.1
12 September 2024
Updated to reflect ACC’s restructure.
1.2
16 September 2025
Updated to reflect ACC’s restructure and
changes to corporate delegations.
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Appendix 1 – Authority
ACC Person/Group
Authority
Engagement & Performance Manager or Performance Monitoring
Conduct, competence or health issues that have been assessed as low risk.
Advisor (the Manager Fraud Prevention & Investigation must be
Cases of overbilling where the total amount of the overbilling is up to
consulted when the matter relates to potential fraud or other criminal $5,000.
issue)
Team Manager Engagement & Performance or Provider Monitoring
Conduct, competence or health issues that have been assessed as low risk.
Manager (the Manager Fraud Prevention & Investigation must be
Cases of overbilling where the total amount of the overbilling is up to
consulted when the matter relates to potential fraud or other criminal $25,000.
issue)
Provider Issues Management Group (the Manager Fraud Prevention Conduct, competence or health issues that have been assessed as medium
& Investigation must be consulted when the matter relates to
or high risk.
potential fraud or other criminal issue)
Cases of overbilling where the total amount of the overbilling is up to
$100,000.
Provider Risk of Harm Group
Conduct, competence or health issues that may pose a risk of harm to the
public.
Manager Health Sector Engagement & Performance or Manager
All conduct, competence or health issues.
Recovery Services (the Manager Fraud Prevention & Investigation
All cases of overbilling.
must be consulted when the matter relates to potential fraud or other
criminal issue)
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Appendix 2 – Remedies
Remedy
Health services provider type
Who can impose
Letter of
Contract for services provider
Engagement & Performance Manager
expectations
Cost of Treatment Regulations provider
Performance Monitoring Advisor
Pre-approved treatment provider
Team Manager Engagement & Performance
Provider Monitoring Manager
Provider Issues Management Group
Provider Risk of Harm Group
Manager Health Sector Engagement & Performance
Manager Recovery Services
Refuse payment of
Contract for services provider
Engagement & Performance Manager
costs of treatment
Cost of Treatment Regulations provider
Performance Monitoring Advisor
Pre-approved treatment provider
Team Manager Engagement & Performance
Provider Monitoring Manager
Provider Issues Management Group
Provider Risk of Harm Group
Manager Health Sector Engagement & Performance
Manager Recovery Services
Accident Compensation Corporation
Page 17 of 21
Health Services Provider Remedies Framework
Approval date: 16 September 2025
Review date: 30 June 2026
link to page 18 link to page 18
GOV-045270
Performance
Contract for services provider
Engagement & Performance Manager
improvement pla
n1
Cost of Treatment Regulations provider
Performance Monitoring Advisor
Pre-approved treatment provider
Team Manager Engagement & Performance
Provider Monitoring Manager
Provider Issues Management Group
Provider Risk of Harm Group
Manager Health Sector Engagement & Performance
Manager Recovery Services
Repayment pla
n2
Contract for services provider
Engagement & Performance Manager
Cost of Treatment Regulations provider
Performance Monitoring Advisor
Pre-approved treatment provider
Team Manager Engagement & Performance
Provider Monitoring Manager
Provider Issues Management Group
Manager Health Sector Engagement & Performance
Manager Recovery Services
1 ACC may issue performance improvement plans to contract for services providers and may agree plans with Cost of Treatment Regulations providers and pre-
approved treatment providers.
2 ACC may agree repayment plans with contract for services providers, Cost of Treatment Regulations providers and pre-approved treatment providers.
Accident Compensation Corporation
Page 18 of 21
Health Services Provider Remedies Framework
Approval date: 16 September 2025
Review date: 30 June 2026
link to page 19 link to page 19
GOV-045270
Contract suspension Contract for services provider only
Team Manager Engagement & Performance
Provider Monitoring Manager
Provider Issues Management Group
Provider Risk of Harm Group
Manager Health Sector Engagement & Performance
Manager Recovery Services
Contract
Contract for services provider only
Provider Issues Management Group
terminatio
n3
Provider Risk of Harm Group
Manager Health Sector Engagement & Performance
Manager Recovery Services
Civil litigatio
n4
Contract for services provider
Provider Issues Management Group
Cost of Treatment Regulations provider
Manager Health Sector Engagement & Performance
Pre-approved treatment provider
Manager Recovery Services
Notification to
Contract for services provider
Provider Risk of Harm Group
responsible authority Cost of Treatment Regulations provider
Manager Health Sector Engagement & Performance
or Health and
Disability
Pre-approved treatment provider
Manager Recovery Services
Commissioner
3 Contract terminations must also be approved in accordance with the Corporate Delegations Policy.
4 Commencing civil litigation must also be approved in accordance with the Corporate Delegations Policy.
Accident Compensation Corporation
Page 19 of 21
Health Services Provider Remedies Framework
Approval date: 16 September 2025
Review date: 30 June 2026
link to page 20 link to page 20
GOV-045270
Notification to law
Contract for services provider
Manager Health Sector Engagement & Performance
enforcement for
Cost of Treatment Regulations provider
Manager Recovery Services
intended
prosecutio
n5
Pre-approved treatment provider
ACC-led
Contract for services provider
Manager Health Sector Engagement & Performance
prosecutio
n6
Cost of Treatment Regulations provider
Manager Recovery Services
Pre-approved treatment provider
5 Manager Health Sector Engagement & Performance or Manager Recovery Services may, following a Fraud Prevention & Investigation team investigation, refer
provider issues involving suspected fraud or other criminal activity to the Prosecution Panel for consideration of notification to law enforcement for intended
prosecution. Such notification must also be approved by a person with delegated authority under the Corporate Delegations Policy.
6 Manager Health Sector Engagement & Performance or Manager Recovery Services may, following a Fraud Prevention & Investigation team investigation, refer
provider issues involving suspected fraud or other criminal activity to the Prosecution Panel for consideration of commencing ACC-led prosecutions. Such
prosecution must also be approved by a person with delegated authority under the Corporate Delegations Policy.
Accident Compensation Corporation
Page 20 of 21
Health Services Provider Remedies Framework
Approval date: 16 September 2025
Review date: 30 June 2026
GOV-045270
Appendix 3 – Notifications
Legislation
Circumstances
Notification
Compulsory notification
Section 45, Health
If a health practitioner (
health practitioner A) or employer
Health practitioner A (who may be employed by ACC) or a
Practitioner
of health practitioners (
health practitioner employer) has
health practitioner employer (which includes ACC) must
Competence
reason to believe that a health practitioner (
health
promptly give the responsible authority written notice of all
Assurance Act 2002
practitioner B) is unable to perform the functions required
the circumstances.
for the practice of his or her profession because of some
health condition.
Optional notification
Section 34, Health
If a health practitioner (
health practitioner A) has reason to Health practitioner A (who may be employed by ACC) may
Practitioner
believe that another health practitioner (
health practitioner give the responsible authority with written notice of the
Competence
B) may pose a risk of harm to the public by practising below
reasons on which that belief is based.
Assurance Act 2002
the required standard of competence.
Section 31, Health
If an action of a health care provider is or appears to be in
ACC or a health practitioner (who may be employed by
and Disability
breach of the Code of Health and Disability Services
ACC) may complain to the Health and Disability
Commissioner Act
Consumers’ Rights.
Commissioner.
1994
Accident Compensation Corporation
Page 21 of 21
Health Services Provider Remedies Framework
Approval date: 16 September 2025
Review date: 30 June 2026
