ACC admits hardline too tough

ACC's rejection stance on elective surgery did not impress Herald readers. Photo / Thinkstock

The ACC has admitted it has been rejecting too many claimants seeking elective surgery following the introduction of a harder-nosed approach three years ago.

The acknowledgement yesterday by a senior ACC official comes after an internal review of elective surgery decision-making which was announced in December during a Herald series on ACC.

Patients, lawyers and advocates vented their objections to the paper over the new approach which had led to many injury claimants being turned down because of age-related degeneration.

The general manager of claims management, Denise Cosgrove, said ACC was implementing recommendations from the review report which were expected to make improvements for claimants.

"We can't automatically say that there will be fewer declines. We hope there will be fewer, we hope fewer will go to review and that fewer are overturned on review."

The report reveals a sharply increased rate of ACC's decisions refusing to pay for surgery being overturned in review hearings: 44 per cent in the nine months to March, compared with 36 per cent in the last financial year, and 30 per cent in 2008/09.

"Too many are being overturned on review," Ms Cosgrove said yesterday.

Elective surgery claims paid by ACC reduced from around 40,000 in 2008/09, to 37,000 in the last financial year. The proportion of declined applications doubled from 11 per cent in 2007/08, to 22 per cent in 2009/10.

During the Herald series,about 400 people complained to the paper about their ACC case. Some lawyers and independent orthopaedic surgeons criticised ACC over its crackdown on surgery access, alleging it relied on brief, weak opinions from its doctors, some of whom had retired from treating patients and were often not specialists in the areas they advised on.

ACC said it was simply applying its legislation more strictly to control spending on elective surgery, which had risen from $128 million in 2005 to $240 million in 2009. This was unsustainable.

In the review report, external stakeholders who were canvassed are cited as criticising the "lack of transparency and independence" of ACC's medical advisers.

"How ACC treats ageing and degeneration in elective surgery decision-making was highlighted by stakeholders in the review as a major issue," the report says.

They told the report writers ACC "may not be getting the balance quite right" in its decisions refusing cover on the basis that a person's injury was caused wholly or substantially by age-related degeneration.

The report says ACC needs to apply extra expertise, particularly in complex cases, before finally deciding to refuse surgery.

Ms Cosgrove said that to improve decision-making, ACC would seek better clinical information from claimants' surgeons at the outset and urge its medical advisers to contact surgeons if more details were needed.

ACC was also working on improving doctors' and the public's understanding of its injury coverage exclusions.

The Orthopaedic Association said it hoped for rapid improvements for patients as a result of the review.

Its president, Associate Professor Gary Hooper, said surgeons were increasingly frustrated at having to appeal for funding of patients' surgery, "even when they apparently met the criteria and were clearly in urgent need".

Former claimant still sceptical

Former ACC claimant Ian Boag remains sceptical despite the corporation's commitment to improve its elective surgery decision-making.

"It's the right thing to say, but I'm sceptical about whether it will make much difference," said 65-year-old Mr Boag, a business owner from Palmerston North.

He had surgery on his left shoulder after a fall in 2009. He paid around $10,000 for the operation, which was reimbursed by Southern Cross.

ACC initially refused to pay, after a medical adviser said Mr Boag had prior degeneration.

Mr Boag sought a legal review and won, with the support of his surgeon. ACC paid him back and he refunded Southern Cross.

"One of the things that pissed me off in the review was that the reviewer said [the medical adviser's] two-line opinion was worthless.

"It's institutional dishonesty. If they can't afford to do [provide elective surgery for everyone who qualifies] they should just say so."