A large proportion of the patients we see at Axis are referred under the Accident Compensation Corporation (ACC) system. ACC is a very important and valuable part of New Zealand's health system, but like many parts of healthcare, it is currently under considerable pressure. As you may know various reviews are underway looking at how services and contracts are delivered, including the specialist contracts used by sport and exercise medicine clinics such as ours.

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Understanding ACC Entitlement and Diagnosis

One important aspect of our contract is that we must consider whether a patient has "ACC entitlement". This definition is set out in law. In practical terms it means that when a patient is referred to us, we must assess the diagnosis and determine whether the condition is likely to be related to an injury event that meets ACC criteria.

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Most of the time this process is straightforward. A patient present with a clear injury, the diagnosis aligns with the mechanism, and treatment continues under ACC without difficulty. For example, a patient with an acute knee injury who is diagnosed with an ACL rupture would usually have clear ACC entitlement. Sometimes the situation is less clear. A referral may arrive with a coded ACC diagnosis that does not align with the clinical findings. A common example is knee, back, or shoulder pain referred under an ACC sprain or ligament injury code where assessment and imaging instead reveal degenerative changes. At some point the original sprain injury may have resolved, and the persisting symptoms relate to a different underlying problem, such as osteoarthritis.

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One important point that is often misunderstood is that ACC accepting an initial sprain diagnosis does not necessarily mean that ongoing care for that condition will remain covered. Sprain and strain injuries are generally expected to recover within a relatively short period. When symptoms persist beyond the expected recovery window, this may well indicate that the original coded diagnosis is no longer the main problem. In those situations the appropriate process is often to submit a revised diagnosis to ACC for review. In practice this happens less often than it should. The process can be complex, and ACC does not always have the capacity to reassess every claim in detail. As a result, patients may continue under an initial injury code even though the underlying diagnosis has evolved.

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As a referral practice, we also see a specific subset of patients who have not improved with initial treatment or those who have had a more significant injury. By definition these are the most complex cases. It is therefore quite common for us to find that the coded diagnosis attached to the claim no longer accurately reflects the patient's condition. When this occurs our role is to make the most accurate diagnosis possible, explain the situation clearly to the patient, and document our opinion in our report. This allows ACC to make an informed decision about entitlement and helps ensure the patient is directed to the most appropriate pathway for ongoing care.

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It is important to emphasise that our role is t to act as ACC case reviewers. Our aim is to support good clinical care and to be constructive partners with patients, referrers, and ACC. At the same time, we do have a contractual obligation to consider entitlement as part of the consultation, and we need to be transparent with patients when the diagnosis suggests that ACC cover may not apply. These situations can sometimes create confusion or distress for patients, particularly if expectations around ACC cover have already been established. Clear referral information from primary care can make a significant difference in reducing this uncertainty.

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How Referrers Can Help:

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When referring patients with possible ACC injuries, a few key pieces of information are particularey helpful.

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• Please do not establish an ACC claim, or refer a patient under ACC, when you not not think that the patient has entitlement.
• Clearly descrive the onset of symptoms and the mechanism of injury. If there was a specific event, outlining what happened and when it occured provides important context.
• Document your working diagnosis in the referral. Even if the diagnosis is provisional, understanding what you suspect helps guide the consultation.
• Include relevant past injuries, previous surgery, or known degenerative conditions that may influence the clinical picture.
• Where possible attached imaging reports or investigation results, and include the radiology provider.
• Providing information about the paient's work role and current work capacity can also be helpful.

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Alternative Pathways and Next Steps

In some cases it may also be appropriate to consider alternative pathways. For example, if the patient has private health insurance and there is a well-established non-ACC diagnosis such as degenerative joint disease, referral under that funding pathway may be more appropriate. If the patient does not have insurance, referral through the hospital system may be preferable. Finally in some situations a patient may be eligible for a gradual process claim. Agood example of this is a stress fracture in a professional athlete, a tendinopathy in a manual worker. These claims can be initiated by a patient's GP (we can help) and can mean that patients have cover for a slection of more chronic conditions.

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Our aim is always to work in partnership with our referring clinicians. Patients with a clear ACC diagnosis, a suspected injury diagnosis, or genuine uncertainty are very appropriate referrals to our service. We are also happy to work with a patient's health insurance.

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Our usual approach is to assess the patient, arrange imaging where required, and continue treatment until the diagnosis is clear. If the condition meets ACC criteria, we will continue management under that pathway. If it becomes clear that the condition does not meet ACC entitlement, we will document this clearly and suggest appropriate alternative pathways for ongoing care.

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Working together in this way helps ensure that patients receive the right care through the right pathways, with clear communication at every step and careful consideration of ACC entitlement. It helps ensure that patients whose conditions meet ACC entitlement criteria can continue under that pathway, while those whose diagnosis no longer fits ACC cover, can be directed appropriately. This supports better patient care and helps protect the long-term sustainability of the ACC scheme.

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ACC is a remarkable system that provides injury cover for New Zealanders, and ensuring its survival requires all of us to work carefully within the framework of the scheme.

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