9 February 2026
Spencer Jones
[FYI request #33169 email]
Kia ora Spencer
Your Official Information Act request, reference: GOV-045270 Thank you for your email of 19 December 2025, asking that we reconsider your request of 8 December
2025 (our reference: GOV-044947) about provider billing and fraud, under the Official Information Act
1982 (the Act).
As you have asked us to reconsider one email request out of 12 emails (sent between 5 and 14
December 2025), we are responding to this request below, as we consider it to be more manageable to
respond to.
I request the following information relating to ACC’s management of provider billing
integrity, audit processes, and fraud-detection systems for the period 1 January 2019 – 31
December 2025 (or the closest period for which data is held):
Information in scope of your request is held by multiple teams within ACC, such as the Provider
Monitoring team, Engagement and Performance team, and the Fraud Prevention and Investigation
team.
We are unable to provide all information requested back to 1 January 2019 without substantial
collation. However, we have provided information for as far back as we can. For example, information
held by the Provider Monitoring team is only readily available from May 2025 onwards. Prior to that
date, ACC used multiple different systems to record information.
Information held by the Engagement and Performance team is only readily available since February
2025 onwards.
As such, we are refusing to provide all information requested back to 1 January 2019 as extracting the
data would require substantial collation and research. This decision has been made under section 18(f)
of the Act. In making this decision, we considered extending our timeframe to respond and charging (as
allowed under the Act). However, it was determined that the resources required to provide the
information would have a significant impact on the everyday functions of the team(s) involved.
1. Provider Audits and Billing Irregularities
1.1 The total number of provider audits conducted by ACC relating to unusual, irregular, or
potentially non-compliant billing.
1.2 The number of providers investigated for any of the following categories of billing
concern (aggregate numbers only):
services billed but not provided
inflated treatment duration
duplicate billing
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retrospective amendments to treatment notes
billing inconsistent with ACC service schedules
any other identified billing anomalies
Table 1: Data on provider interventions managed by the Provider Monitoring team and Engagement and
Performance team
Issue
Total
Admin billing error
52
Delayed billing
23
Double billing
95
Incorrect Billing
537
Other
208
Notes about Table 1:
• Note that some of the cases under ‘Incorrect Billing’ could be double ups, as we have
combined data from two teams. We are unable to tell without a manual review whether any of
those cases were counted twice.
• Most of the data above is from the Provider Monitoring team and is from May 2025 to 13 January
2026. Some data in the ‘Incorrect Billing’ row is data from the Engagement and Performance
team between February 2025 to 13 January 2026.
• ‘Admin billing errors’ are when the incorrect amount has been entered when billing.
• ‘Incorrect billing’ can range from travel billing issues, high hourly billing, incorrect codes, etc.
• ‘Other’ includes the following issue categories:
o ‘Causation’ refers to billing for treatment for something that is not related to the
covered injury.
o ‘Necessary and appropriate’ means ACC considered whether the treatment invoiced for
was necessary and appropriate for the covered injury and meets the ACC legislative
requirements for what we can fund.
o ‘Same day treatment’ is where a provider has billed for too many treatments in a day for
a single client.
o ‘Treatment of family/colleagues/self.’ ACC agrees with the Medical Council of New
Zealand that other than in exceptional circumstances providers shouldn't provide
medical care to themselves or anyone with whom they have a close personal
relationship.
o ‘Telehealth’ relates to not following Telehealth billing guidelines.
o ‘Blank/not specified’ mostly relate to provider travel billing issues.
Fraud Prevention and Investigation data
The Fraud Prevention and Investigation team are separate to the Provider Monitoring team and
Engagement and Performance team. Between 1 January 2019 and 31 December 2025, Fraud
Prevention and Investigation closed a total of 132 provider cases (interventions and investigations).
Please note, some provider cases may overlap with the figures provided by the other teams as there are
situations where cases are escalated to Fraud Prevention and Investigation. Until recently, the Fraud
Prevention and Investigation system did not record issue type, so we are unable to provide categories
of billing concerns.
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1.3 The number of these investigations where billing irregularities, overcharging, or fraud
were substantiated.
Table 2: The outcome of actions undertaken for provider interventions managed by the Provider
Monitoring team and Engagement and Performance team
Outcome of actions undertaken by ACC
Total
Behaviour change
527
Recovered payment
146
Breach of contract notice issued
3
Blank/not specified
241
Notes about Table 2:
• ‘Behaviour change’ mostly relates to ACC providing education to providers or suppliers. In
some cases, there was a recommended contract change.
• ‘Blank/not specified’ sometimes relates to payments recovered or provider/supplier education.
• The cases where a breach of contract notice was issued could also be included in one or more
of the other categories within Table 2.
Fraud Prevention and Investigation data
Of the total 132 provider cases closed by the Fraud Prevention and Investigation Team, we
substantiated 50 cases of fraud or abuse-indicated behaviour.
2. Outcomes and Recoveries
2.1 The total amount recovered by ACC from providers (annual figures), broken down into:
overpayments
overbilling
fraudulent claims
audit adjustments
voluntary repayments after audit findings
(If already held in a consolidated internal report, providing that report would satisfy this
request.)
Table 3: Total payments recovered which were managed by the Provider Monitoring team and
Engagement and Performance team
Issue
Total amount recovered
Admin billing error
$80,621
Incorrect billing
$304,717
Incorrect billing (Engagement and Performance team)
$127,173
Double billing
$34,422
Necessary and appropriate
$141,658
Telehealth
$6,504
Notes about Table 3:
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• Most of the data above is from the Provider Monitoring team and is from May 2025 to 13 January
2026. The second ‘incorrect billing’ row is data from the Engagement and Performance team
between February 2025 to 13 January 2026.
• There could be some overlap between the data held by separate teams which would require a
manual review to determine.
• Telehealth relates to not following Telehealth billing guidelines.
• We do not have data for all of the above categories you have specified such as ‘audit
adjustments’ and ‘voluntary repayments after audit findings.’ As such, we are refusing this part
as it is not held. This decision has been made under section 18(g) of the Act.
2.2 The number of providers who:
were subject to corrective action plans
were suspended from delivering services
had contracts terminated
were referred to Police, Serious Fraud Office, or other regulatory bodies
Provider Monitoring team and Engagement and Performance team
Please see Table 2 above regarding the outcome of actions taken.
We did not locate any contracts terminated or suspensions which related to billing issues. As such, we
are refusing this part of your request, as the information does not exist or, despite reasonable efforts to
locate it, cannot be found. This decision has been made under section 18(e) of the Act.
Fraud Prevention and Investigation data
Between 1 January 2019 and 31 December 2025, two provider cases were referred to Police by Fraud
Prevention and Investigation.
Notifications to Responsible Authorities (regulatory bodies)
There were 121 notifications to Responsible Authorities between 1 January 2019 and 28 January 2026.
However, most of these do not relate to billing issues. Some relate to fraud, risk of harm, or
professional conduct or competence.
3. Categories of Providers
3.1 For analysis and public transparency purposes, please provide high-level categories
(not names) of provider types that have been the most frequently identified with billing
irregularities from 2019–2025.
Examples may include: physiotherapy, chiropractic, pain management, vocational rehabilitation, occupational
therapy, radiology, specialist assessment providers, etc.
I am not requesting individual provider identification.
Between May 2025 to 13 January 2026, the provider types which have the most billing-related issues
logged are listed below. These are not listed in any order.
• Acupuncturist
• Physiotherapist
• Occupational Therapist
• Psychologist
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• Dentist
• Support worker
Please also note that the above data is only based on a short time-period and may change if it were for
a longer time period.
4. Fraud-Detection Framework and Audit Thresholds
4.1 Copies of any internal ACC documents that outline:
fraud-detection methodology
billing-anomaly detection rules
red-flag indicators
audit thresholds
internal referral pathways for suspected provider misconduct
monitoring or performance-assurance procedures used by ACC to detect potential
irregularities
We are refusing to provide copies of any documents held by ACC which outline:
• fraud-detection methodology
• billing-anomaly detection rules
• red-flag indicators
Release of this information would be likely to prejudice the maintenance of the law, including the
prevention, investigation, and detection of offences, and the right to a fair trial. This decision has been
made under section 6(c) of the Act.
In 2025 ACC began moving towards more proactive detection of irregular provider behaviour, with a
provider monitoring tool in development. This tool will use detection flags to assign risk scores to
providers, to identify the appropriate intervention level.
To answer the other parts of this request, please see attached or linked the following:
• Understanding your responsibilities
- https://www.acc.co.nz/for-providers/provide-
services/understanding-your-responsibilities
• Health Services Provider Remedies Framework
If you have any questions about this response, please get in touch You can email me at
[email address]. If you are not happy with this response, you can
also contact the Ombudsman vi
a [email address] or by phoning 0800 802 602.
Information about how to make a complaint is available at
www.ombudsman.parliament.nz. Ngā mihi
Christopher Johnston
Manager Official Information Act Services Government Engagement
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