Part 1: Introduction

Accident Compensation Corporation: Case Management of Rehabilitation and Compensation.

Why Did We Do This Audit?

1.1
The Accident Compensation Corporation Te Kaporeihana Awhina Hunga Whara (ACC) is a Crown entity that administers the accident compensation scheme, which provides 24-hour, no-fault accident insurance and assistance for everyone, whether New Zealand citizens, residents, or temporary visitors to the country. In return, people do not have the right to sue for damages for personal injury, other than for exemplary damages.

1.2
ACC spent about $1,700 million during the 2002-03 financial year on rehabilitation, treatment, and weekly compensation.3 To pay for these services, ACC collects, directly or indirectly, levies (or premiums) from most New Zealanders, and earns income by investing funds. ACC is a high-profile organisation that attracts Parliamentary select committee and media interest, often because of complaints by members of the public.

1.3
We undertook this audit of ACC because we considered that an independent report by us would:

  • provide both an insight into the work of ACC, and assurance about the compliance of current ACC operational structures, systems, and processes with key legislative requirements; and
  • make a useful contribution to any future public or political debate by adding to the understanding of ACC and its activities.

1.4
Our objective in undertaking this audit was to produce a report that is useful for:

  • the general public – who will benefit from a clear exposition of ACC’s roles, functions, obligations, and performance against its governing legislation (the Injury Prevention, Rehabilitation, and Compensation Act 2001 (the Act));
  • ACC levy payers – by providing assurance about ACC’s performance, especially in relation to the management of high-risk and high-cost claims;
  • claimant support and advocacy groups, and Members of Parliament – by providing them with information on how ACC operates, and the limitations on its functions; and
  • ACC – by providing it with an independent assessment of its operations, with recommendations for improvements.

Audit Scope

1.5
ACC is a complex organisation with a range of functions, responsibilities, and activities.

1.6
We looked broadly at ACC’s method of claims processing4 before focusing particularly on case management practices at ACC branches. This report therefore:

  • describes the systems, processes, standards, and methodologies that ACC has in place to ensure that it fulfils its obligations under the Act;
  • documents and assesses ACC’s internal audit, evaluation, and reporting mechanisms, which are used to ensure the consistent application of performance measures and standards nationwide;
  • identifies issues and factors that have a bearing on rehabilitation outcomes;
  • identifies those aspects of ACC’s systems and capabilities that influence the management and administration of claims, and particularly case management; and
  • makes recommendations about improvements to current systems and processes.

1.7
Because of ACC’s size and complexity, and in order to make the audit manageable, we excluded the following:

  • ACC’s Healthwise business unit, which is responsible for the purchase of health services.
  • Financial management and actuarial aspects of ACC’s business.
  • Injury prevention activities, such as the Safety on Roads and Sportsmart initiatives. While we recognise that injury prevention is an important activity for ACC, in this audit we have limited our examination mostly to ACC’s rehabilitation activities.
  • A review or reconsideration of the circumstances or outcomes of a particular claimant or claim. Although we looked at specific cases to help us understand the wider issues of case management, the rights or wrongs of specific cases are properly dealt with through external dispute resolution bodies.
  • An assessment of the activities of ACC’s subsidiary business, Dispute Resolution Services Limited, which conducts claim reviews. However, we do discuss its role within ACC’s case management process.

Audit Expectations

1.8
In preparing for this audit, we drew up expectations against which we could assess ACC’s case management performance. We list these expectations in the next paragraph and refer in brackets to the parts of the report where they are specifically discussed.

1.9
We expected that ACC’s policies and procedures would ensure:

  • timely management of claims received (paragraph 3.23);
  • consistent determination of cover and entitlements in compliance with the Act (compliance: paragraphs 3.2-3.16 / cover: paragraphs 2.7-2.10, 3.9, 3.11, 3.21-3.22 / entitlements: paragraphs 2.11-2.12, 3.10, 3.12-3.14, 3.22, 4.15);
  • the provision of advice and information to claimants about their rights and entitlements within the time and in the manner required by the Act, and the Code of ACC Claimants’ Rights (Individual Rehabilitation Plans: paragraphs 4.35-4.52 / advice on entitlements: paragraph 6.11 / Code of ACC Claimants’ Rights: paragraphs 6.4-6.7 / Catalyst5, the Act, and the Code of ACC Claimants’ Rights: paragraphs 4.90-4.96);
  • that case managers are appropriately skilled, experienced, and supported by ACC management in order to comply with the Act and to provide claimants with their entitlements (skills, experience, and training: paragraphs 5.6-5.22 / support: paragraphs 4.3-4.34 / Catalyst case managers: paragraphs 4.93-4.96, 5.33-5.39);
  • effective monitoring, quality assurance, and auditing of critical aspects of case management performance (monitoring and quality assurance of branch performance: paragraphs 4.65-4.73 / file review and audit: paragraphs 4.74-4.89 / monitoring and assessment of case managers: paragraphs 5.23-5.29);
  • the identification and application of best practice throughout the organisation (paragraphs 3.32-3.33); and
  • appropriate consultation with key stakeholder groups in the development of policy or operational initiatives that affect case management practices (paragraphs 2.46-2.53, 3.18).

How We Conducted Our Audit

1.10
In conducting the audit we:

  • met with ACC’s management and other staff from ACC’s Head Office, as well as other offices in Wellington, viewed ACC’s policies and procedures, and conducted file reviews;
  • met with ACC staff in the service centres and selected contact centres and branches, and observed compliance with ACC’s policies and procedures;
  • visited third parties who interact with ACC, to discuss their views of ACC – including claimants, health service providers, employers, claimant support groups, and other government agencies; and
  • consulted specialist advisers about the content of our report.

Meetings With ACC Management

1.11
We met with ACC’s senior management team to define the focus of our audit and to familiarise ourselves with ACC’s strategic and business planning, performance monitoring and management, human resources capability, and operational focus. After these meetings, we viewed ACC’s policies and procedures in preparation for field work. On completion of our regional field work, we had numerous follow-up meetings with selected managers at Head Office.

Meetings With ACC Staff

1.12
We conducted initial field work at the Dunedin service centre, contact centre, and branch (see the map in Figure 5 on page 40). At the service centre we observed the process followed by ACC staff when they receive a claim, register it, and decide whether or not the claim is covered by the accident compensation scheme. At the contact centre, we saw how ACC staff deal with claims that require more active management because of the nature of the injury suffered by the claimant.

1.13
Our field work at the Dunedin branch gave us the necessary context for our audit work at other branches by giving us an understanding of how claims flowed into the branch from the service and contact centres.

1.14
Also at the Dunedin branch, we observed how ACC staff undertake intensive case management of high-risk claims, which gave us a better understanding of:

  • how decisions are made about cover and entitlements;
  • the provision of treatment, and social and vocational rehabilitation;
  • how claims are closed; and
  • how case managers processed claims and used the support tools available to them (for example, information technology and training).

1.15
After these visits we concluded that, because the lengthy and complex claims are managed at ACC branches, we needed to concentrate our audit on the branches. Accordingly, our discussion of service and contact centres in this report is limited to a description of how their operations relate to those of the branches.

1.16
Before we started our second phase of field work, we met with two ACC managers who have a wealth of knowledge and experience in case management. During this meeting, we discussed the scope and methodology of our audit approach to ensure that they were appropriately targeted.

1.17
The second phase of our field work involved visits to ACC branches in Auckland, Hamilton6, New Plymouth, Wanganui, Porirua, Blenheim, and Papanui.

1.18
We visited the Auckland and Christchurch offices of Catalyst, based in the Takapuna and Papanui ACC branches respectively; and we met with the Catalyst General Manager in Wellington.

1.19
We decided from the outset that it was not practical for the audit team to visit and conduct file reviews at all of ACC’s 307 branches. Instead, we selected a mixture of branches from places with different population characteristics, and branches that were noted for their different levels of performance in ACC’s weekly branch reports.

Meetings With Third Parties

1.20
During field work in Auckland, Hamilton, and Wanganui, we spoke with a range of health service providers, including a Māori health provider, and some largerscale employers, to get their views of ACC’s performance.

1.21
Our field work in Wellington and New Plymouth involved meetings with past and present ACC claimants8, and we also met claimant support groups in Hastings and New Plymouth. These meetings were valuable for us to consider claimant opinions of ACC’s performance.

1.22
We met with staff from the Office of the Ombudsmen (in Wellington and Christchurch) to discuss the nature of the complaints that they receive from ACC claimants, and the process that the Office follows with ACC when processing the complaints. We also met with a staff member from the national office of Work and Income9 to discuss the service’s claimant transfer protocol with ACC.

Advisers

1.23
We consulted specialist advisers in the areas of occupational health, case management, and law to provide additional assurance that this report is based on sound information.

3: The Accident Compensation Corporation Annual Report 2003 notes that ACC spent about $951 million on rehabilitation services (including vocational and social rehabilitation) and about $753 million on compensation (including income maintenance).

4: The term ‘claims processing’ describes the time from when ACC receives a claim to when the claim is closed.

5: Catalyst Injury Management Limited – a wholly owned subsidiary of ACC.

6: We also visited the service and contact centres in Hamilton.

7: For completeness, we counted Thames as a branch even though it is administered from Tauranga.

8: We selected claimants to interview by asking a sample of general practitioners to ask some of their ACC patients if they would be happy to discuss their views about ACC with us.

9: Work and Income is a service of the Ministry of Social Development.

page top