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SIRA's Supervision of Relevant Service Providers: Information for Providers

This guide outlines how the State Insurance Regulatory Authority (SIRA) supervises and regulates relevant service providers (i.e., health and related service providers) who offer services in the workers’ compensation (WC) and motor accidents compulsory third-party (CTP) schemes.

It answers questions about SIRA’s regulatory role, approach to supervision, and when and how SIRA may issue a direction to providers who aren’t doing the right thing.

1. What are SIRA’s regulatory powers with respect to relevant services?

SIRA has the power to give a direction to a relevant service provider (RSP) providing services in the NSW workers compensation and motor accident schemes.

Part 2, Division 3 of the State Insurance and Care Governance Act 2015Clause 4A-4F, State Insurance and Care Governance Regulation 2021Guidelines for provision of relevant services (health and related services)

Commenced June 2022 and gave SIRA power to:

  • give a direction to a RSP to provide information/data (section 26C direction), take specified action or provide/not provide specified relevant services (section 26D direction)
  • publish names on a register
  • make regulations and issue guidelines.

The Act also provides for internal review and administrative review of directions, and penalties for non-compliance with a direction.

Commenced December 2022 and includes:

  • definition of relevant service
  • circumstances in which a direction can be given, i.e.:
    • non-compliance with the workers compensation and/or motor accidents legislation
    • non-compliance with guidelines issued under the SICG Act or the workers compensation and motor accidents legislation
    • the RSP has been referred to, or is under investigation by, a relevant clinical, professional or accreditation body.

Commenced 8 December 2023 and includes:

  • a code of conduct for RSPs
  • requirements for service provision
  • requirements for billing and invoicing.

What are relevant services?

Relevant services are medical, medico-legal, allied health, rehabilitation and other related healthcare and administrative services provided in connection with a claim under the NSW workers compensation and motor accidents schemes.
The full list of relevant services is set out in in clause 4A of the State Insurance and Care Governance Regulation 2021 and is included at Appendix A of this document.

Who are relevant service providers?

Relevant service provider (RSP) means a person, organisation or body providing a relevant service in the NSW workers compensation and motor accidents schemes.
This includes medical, medico-legal, allied health, rehabilitation and other related healthcare and administrative service providers. Refer to the full list at Appendix A.
The following are not relevant service providers:

  • a public hospital, local health district, specialty network governed health corporation, the Health Administration Corporation and Health Protection NSW
  • the Ambulance Service of NSW.

What do RSPs need to comply with?

RSPs are required to comply with applicable provisions in the:

  • workers compensation legislation and the regulations and guidelines made under those Acts, including fees orders
  • motor accidents legislation and the regulations and guidelines made under those Acts
  • The State Insurance and Care Governance Act 2015 (SICG Act) and regulation and guidelines issued under the SICG Act.

For information on what is included under the first two dot points, see Appendix B, which provides the full list of legislation, Regulations, Guidelines and Fees Orders that must be complied with under the workers compensation and motor accidents legislation.

2. How does SIRA supervise relevant service providers?

What is SIRA’s approach to supervising RSPs?

SIRA’s regulatory approach is:

  • customer-centric: protecting the interests of its customers (policy holders and people who make claims, now and in the future)
  • intelligence-led: using the right data and insights to inform regulatory action
  • risk-based: rating risks and issues to flexibly select the most appropriate regulatory response that is proportional to the risk.

What types of RSP behaviour will SIRA regulate?

SIRA regulates non-compliance with the workers compensation and motor accidents legislation and the regulations and guidelines made under those Acts, and the SICG Act and guidelines made under that Act (see list at Appendix B).

Some examples of matters that SIRA may investigate include:

  • reports that don’t comply with requirements in guidelines
  • delivery of services without required pre-approval
  • billing for amounts that are more than the maximum fee fixed by SIRA
  • billing services the RSP is not eligible to provide- e.g., billing a medical specialist item when they are not one
  • servicing patterns which vary significantly from the RSP’s peers, considering factors such as the complexity/severity of injuries being treated.

In this context, SIRA regulatory activity will in general be most focussed on:

  • providers with a pattern of non-compliance
  • business models not serving the best interests of injured people.

What types of RSP behaviour will SIRA not regulate?

In general, SIRA will not investigate concerns about a RSP’s clinical or professional conduct or intervene in individual clinical decision-making.

If clinical concerns arise, and SIRA considers there is a potential risk to an injured person’s health or welfare, SIRA may choose to refer the matter to an appropriate body with the expertise to investigate, such as the Health Care Complaints Commission, the Health Professional Councils Authority, or other relevant body.

Examples of clinical or professional concerns SIRA may refer include:

  • poor clinical practice
  • impairment arising from a health condition or drug and alcohol use
  • sexual misconduct, or inappropriate relationship with a patient
  • patterns of servicing where there is doubt that the services are clinically justified.

SIRA may give a direction to RSPs who have been referred to, or are under investigation by, a relevant clinical, professional or accreditation body.

How does SIRA detect non-compliance or clinical concerns?

Concerns or issues with RSPs come to SIRA’s attention from a range of sources, such as:

  • analysis of scheme data such as billing and servicing data, and identification of trends or patterns of incorrect, anomalous or outlier behaviour such as overcharging or overservicing.
  • complaints regarding the conduct or performance of an RSP.  These may come from a range of sources, including an injured person/family member, another service provider, a professional association/college, an employer or an insurer.  These complaints may come to SIRA directly or be referred to SIRA from somewhere else.
  • data exchange with other regulatory bodies, such as: the Health Care Complaints Commission, the Australian Health Practitioner Regulation Agency as well as insurance, compensation or health authorities, government agencies, statutory bodies, or private hospitals.

What actions may SIRA take in response to non-compliance before giving a direction?

In general, SIRA will engage with a RSP before giving a direction.  However, SIRA may need to take immediate action- such as giving a direction, if there is a risk of harm.

SIRA will consider a range of factors to ensure engagement and actions are appropriate, proportionate, and effective, and that the RSP is afforded procedural fairness.

Examples of actions that could be taken include:

  • SIRA may contact the RSP to discuss the matter, help identify the causes of non-compliance, and provide support and education to remedy any gaps in understanding.
  • SIRA may write to the RSP, informing them where they are failing to meet requirements, how to comply with requirements, and that SIRA has the power to give a direction, and then publish their name on a register, if requirements are not complied with.

RSPs will be given the opportunity to make submissions about their behaviour including why further compliance activity (such as a direction) is not warranted.

SIRA may inform and seek the assistance and advice of relevant clinical, professional or accreditation bodies, where appropriate, as part of ensuring that SIRA actions are appropriate, proportionate and effective.

How does SIRA assess the risk of non-compliant behaviour?

Factors SIRA may consider in determining risk and a proportional response to the issue include:

  • the nature and seriousness of the issue
  • the actual or potential harm to injured people or the schemes
  • whether the RSP has been cooperative in its interactions with SIRA
  • any previous regulatory actions taken by SIRA and the RSP’s ability to return to compliance
  • what the regulatory action is expected to achieve, and what impact or outcomes SIRA wants.

What about insurers who approve non-compliant behaviour?

Insurers also have compliance obligations and should be ensuring that SIRA requirements such as maximum fees are complied with.

SIRA monitors insurer compliance and performance and takes appropriate compliance action to address concerns such as poor payment controls.

It is a condition of an insurer’s licence not to engage, approve or pay relevant service providers who have been given directions not to provide specified relevant services under section 26C(1)((c) or not to provide any relevant services under section 26D(1)(d).

Will RSPs have the opportunity to discuss the situation before a direction is given?

SIRA will generally engage with the RSP to assist them and give them reasonable opportunity to rectify non-compliant behaviour.

An exception to this would be in cases where SIRA considers there is risk of harm to injured people and/or the schemes and immediate action – i.e., the giving of a direction is needed.

The preference is to assist RSPs come into compliance, rather than giving directions. This means that (except as outlined above) SIRA staff will generally discuss the matter with the RSP, help identify the causes of non-compliance, and provide support and education to remedy any gaps in understanding.

Warning letters may also be written, informing the RSP where they are failing to meet requirements, how to comply with requirements, and that SIRA has the power to give a direction and publish their name on a register if requirements are not complied with.

If the non-compliance continues, SIRA may also consider giving the RSP a direction.

SIRA’s actions will also depend on the risk to injured people and the schemes.

SIRA recognises that the vast majority of RSPs providing services in the schemes are doing the right thing, and that mistakes can be made.

Will RSPs be notified that there is a problem before SIRA gives a direction?

In general, SIRA will engage with a RSP before giving a direction, unless there is a risk of harm that makes immediate action an appropriate and proportionate response.

The purpose of this engagement is to give the RSP a reasonable opportunity to explain their position, understand SIRA requirements, and come into compliance.

It will also help ensure SIRA’s actions are appropriate, proportionate, and effective, and that the RSP is afforded procedural fairness.

In cases where SIRA has determined there is a risk of harm, the RSP may not receive any notification or engagement before the direction is given.

3.  Will SIRA regulate the clinical practice of health practitioners?

What will SIRA do if there are concerns about the clinical practice of an RSP?

In general, SIRA will not investigate concerns about a RSP’s clinical or professional conduct or intervene in individual clinical decision-making.

If clinical concerns arise, and SIRA considers there is a potential risk to an injured person’s health or welfare, SIRA may choose to refer the matter to an appropriate body with the expertise to investigate, such as the Health Care Complaints Commission, the Health Professional Councils Authority, or other relevant body.

Examples of clinical or professional concerns SIRA may refer include:

  • poor clinical practice
  • impairment arising from a health condition or drug and alcohol use
  • sexual misconduct, or inappropriate relationship with a patient
  • patterns of servicing where there is doubt that the services are clinically justified.

SIRA may give a direction to RSPs who have been referred to or are under investigation by one of these bodies.

4.What directions can SIRA give?

What directions may SIRA give under the State Insurance and Care Governance Act 2015 (SICG Act)?

There are two types of directions:

  • a direction given under section 26D of the SICG Act - in response to an RSP’s non-compliance with SIRA legislation or referral to a clinical or professional body
  • a direction given under section 26C of the SICG Act - a request for the RSP to provide data.

What is a section 26D direction?

Under section 26D of the SICG Act, SIRA may give a written direction requiring the RSP:

  • to take specified action, or provide specified information, concerning specified relevant services (s26D(1)(a))
  • to provide specified relevant services in a specified way (s26D(1)(b))
  • not to provide specified relevant services (s26D(1)(c))
  • not to provide any relevant services (s26D(1)(d)).

Under Clause 4C(3) of the Regulation, SIRA may give a section 26D direction where the RSP has:

  • not complied with a provision of the workers compensation and motor accidents legislation (cl 4C(3)(a) of the Regulation)
  • not complied with guidelines issued under s26E of the SICG Act, or the workers compensation and motor accidents legislation (cl4C(3)(b) of the Regulation)
  • been referred to, or is under investigation by, a relevant clinical, professional or accreditation body (cl4C(3)(c) of the Regulation).

What is a section 26C direction?

Under section 26C of the SICG Act SIRA may give a written direction requiring the RSP to provide SIRA with specified data within a specified period.
The circumstances under which SIRA may request data via a s26C direction are not specified in the Act or the Regulation. However, SIRA may give a s26C direction for a variety of reasons. For example, these could include for the purposes of investigation, or to gather information about services provided in the WC and CTP schemes.

5. What is a direction given under section 26D and how is it given?

What type of directions may be given under section 26D?

Under section 26D of the SICG Act, SIRA may give a written direction requiring a RSP:

  • to take specified action, or provide specified information, concerning specified relevant services (s26D(1)(a))
  • to provide specified relevant services in a specified way (s26D(1)(b))
  • not to provide specified relevant services (s26D(1)(c))
  • not to provide any relevant services (s26D(1)(d)).

In what circumstances may a direction under section 26D be given?

SIRA may give a section 26D direction where the RSP has:

  • not complied with a provision of the workers compensation and motor accidents legislation (cl 4C(3)(a) of the Regulation)
  • not complied with guidelines issued under s26E of the SICG Act, or under the workers compensation and motor accidents legislation (cl4C(3)(b) of the Regulation)
  • been referred to, or is under investigation by, a relevant clinical, professional or accreditation body (cl4C(3)(c) of the Regulation).

Who will make the decision to give a direction under section 26D?

The decision to give a section 26D direction lies with the Chief Executive of SIRA. The Chief Executive may delegate authority to do so to a SIRA executive.

What information will be included in a direction under section 26D?

A section 26D direction will be given in writing and include the following:

  • the reasons for the direction
  • the day the direction takes effect (usually the day it is given, but could be a later day)
  • the day until which the direction will remain in force
  • the action the RSP is to take, or refrain from taking
  • the information that will be included in the public register of RSPs given directions under s26D, to be published on the SIRA website
  • a statement that non-compliance with the direction is an offence and may result in the issuing of a penalty notice and/or further action
  • a statement that the RSP is entitled to:
    • (i) for a direction given under section 26D(1)(a) or (b) of the SICG Act- an internal review of the direction, or
    • (ii) for a direction given under section 26D(1)(c) or (d) of the SICG Act- an administrative review of the direction under section 26F the Act.

How will a section 26D direction be given?

The direction will be given in writing.
SIRA must give the direction personally or electronically (to an address or location specified by the RSP for receiving directions under the section).

Will the names of people given directions under section 26D be published?

Section 26G (1) of the SICG Act provides that SIRA may keep a public register of relevant service providers given directions under s26D.

The register will be publicly available on the SIRA website.

The register allows for insurers, legal practitioners, injured people and other scheme participants to be aware of RSPs who have been excluded, suspended, had their practice limited or been asked to take specific action.

The register may include:

  • the RSP’s name
  • the RSP’s ABN and/or Australian Health Practitioner Regulation Agency registration number, or professional association registration number, as applicable
  • the RSP’s SIRA provider number (if applicable)
  • the relevant services provided by the RSP
  • information relating to the direction given to the RSP, including:
    • the direction given, and
    • the date the direction came into effect and any expiry date.

SIRA will update the register within seven days of a direction being varied or revoked because of an internal review or NSW Civil and Administrative Tribunal administrative review determination.

Can an RSP get a review of a decision to give them a section 26D direction?

Yes. The written direction will include details on review options available.

These include an internal review by SIRA and/or an administrative review by the NSW Civil and Administrative Tribunal, depending on the type of section 26D direction.

What is the penalty for failure to comply with a section 26D direction?

A RSP must comply with a direction given to the provider under s26D.

Non-compliance with the direction given is an offence. If found guilty of this offence, the maximum penalty for not complying is 500 penalty units ($55 000) for a corporation or 100 penalty units ($11 000) for an individual.

Section 29B of the SICG Act also makes non-compliance with a direction a penalty notice offence, meaning that, depending on the specific circumstances of the non-compliance with the direction, SIRA may issue a penalty notice with a prescribed penalty of up to $1250 for a corporation or up to $750 for an individual.

Will SIRA give a s26D direction every time there is non-compliance, or if it refers someone to a clinical or professional body?

SIRA will consider a range of factors to come to a decision that is appropriate, proportionate and effective.

SIRA expects that most issues will be remedied in discussion with the provider before a direction needs to be issued.

Where appropriate, SIRA will give RSPs reasonable opportunity to educate themselves on regulatory requirements and return to compliance before taking action under the legislation.

SIRA’s actions will also depend on the risk to injured people and the schemes.

SIRA recognises that the vast majority of RSPs providing services in the schemes are doing the right thing, and that mistakes can be made.

6. What is a section 26C direction and how is it given?

What is a s26C direction?

Under section 26C of the SICG Act SIRA may give a written direction requiring the RSP to provide SIRA with specified data within a specified period.

What kinds of data may SIRA request from RSPs and why?

SIRA may seek claim-related data such as written documents, records, or other materials (for example case notes, file notes, invoices, travel logs, reports, or billing related documents) held by the service provider concerning relevant services that they provide.

SIRA may request data for investigation, research, and other reasons.

SIRA may request specific data from individual RSPs.

It may also request the same data from a category of RSPs. For example, SIRA could request that all private hospitals provide specific data about the outcomes of certain private hospital services.

What information will be included in a s26C direction?

A 26C direction will be given in writing and include the following:

  • the specified data being requested
  • the reasons for giving the direction
  • the date the direction takes effect (usually the day it is given, but could be a later day)
  • the date the data is to be provided to SIRA
  • how the data is to be provided
  • advice that non-compliance with the direction is an offence and may result in further action eg issuing of a penalty notice.

How will a s26C direction be given?

The direction will be given in writing. SIRA will give the direction personally or electronically (to an address or location specified by the RSP for receiving directions).

Is a section 26C direction a compliance action by SIRA?

Not necessarily. SIRA may request data using a s26C direction for a variety of reasons.

This includes investigation of non-compliance, but can also include, for example, gathering of information about aspects of the personal injury schemes SIRA regulates.

Can an RSP get a review of a decision to give them a section 26C direction?

There is no statutory right of review of a section 26C direction in the SICG Act, as there is with a section 26D direction.

However, the RSP may ask SIRA to review the request for data.

How will personal or health information in the data be managed?

SIRA may give a written direction to a RSP under section 26C(3) of the SICG Act that may require them to provide data that is personal information or health information about an individual despite anything contrary in the Privacy and Personal Information Protection Act 1998 or the Health Records and Information Privacy Act 2002.

SIRA will ensure that its requests for access to any personal or health information contained in confidential data or clinical files are managed in accordance with privacy legislation and the SIRA Privacy Management Plan.

Will the names of people given directions under section 26C be published?

There will be no public register of RSPs given s26C directions. There is no provision in the legislation for such a register.

What is the penalty for failure to comply with a s26C direction?

A RSP must comply with a direction given to the provider under s26C.

Non-compliance with the direction given is an offence. If found guilty of this offence, the maximum penalty for not complying is 500 penalty units ($55 000) for a corporation or 100 penalty units ($11 000) for an individual.

Section 29B of the SICG Act also makes non-compliance with a direction a penalty notice offence, meaning that, depending on the specific circumstances of the non-compliance with the direction, SIRA may issue a penalty notice with a prescribed penalty of up to $1250 for a corporation or up to $750 for an individual.

7. Will there be procedural fairness for RSPs?

What principles will underpin SIRA decision-making?

SIRA’s decision-making regarding RSPs will comply with administrative law principles. SIRA will:

  • comply with applicable legislation
  • provide procedural fairness
  • consider only relevant matters
  • give the RSP the opportunity to make submissions
  • act in good faith.

SIRA will consider a range of factors to ensure decisions are appropriate, proportionate, and effective, and that the RSP is afforded procedural fairness.

Will the RSP have the opportunity to discuss the situation before a direction is given?

SIRA will generally engage with the RSP to assist them and give them reasonable opportunity to rectify non-compliant behaviour.

SIRA expects that most issues will be remedied in discussion with the provider before a direction needs to be issued.

Where appropriate, SIRA will give RSPs reasonable opportunity to educate themselves on regulatory requirements and return to compliance before taking action under the legislation.

If the RSP continues to be non-compliant, warning letters may also be written, informing the RSP where they are failing to meet requirements, how to comply with requirements, and that SIRA has the power to give a direction and publish their name on a register if requirements are not complied with.

If the non-compliance continues, SIRA may also consider giving the RSP a direction.

SIRA’s actions will also depend on the risk to injured people and the schemes.

SIRA recognises that the vast majority of RSPs providing services in the schemes are doing the right thing, and that mistakes can be made.

An exception to this would be in cases where SIRA considers there is risk of harm to injured people and/or the schemes and immediate action – i.e., the giving of a direction - is needed.

Will the RSP be informed before a direction is given?

As above, in general, SIRA will engage with a RSP before making the decision to give a direction.

This engagement will include noting the ramifications for the RSP of continuing non-compliance, including that SIRA may give a direction and publish the RSP’s name on the register.

However, in some cases, SIRA may need to take immediate action – eg give a direction - if there is a risk of harm.

Will the RSP have the right to make submissions and be heard before a direction is given?

In general, SIRA will engage with a RSP before giving a direction, unless there is a risk of harm that makes immediate action an appropriate and proportionate response.

For example, SIRA may:

  • contact the RSP to discuss the matter, help identify the causes of non-compliance, and provide support and education to remedy any gaps in understanding of SIRA requirements
  • write to the RSP, informing them where they are failing to meet requirements, how to comply with requirements, and that SIRA has the power to give a direction, and then publish their name on a register, if requirements are not complied with.

During this type of engagement, the RSP will have the opportunity to make submissions.

The purpose of this engagement is to give the RSP a reasonable opportunity to explain their position, understand SIRA requirements, and come into compliance.

It will also help ensure SIRA’s actions (such as any subsequent decision to give a direction) are appropriate, proportionate, and effective, and that the RSP is afforded procedural fairness.

Will the RSP be informed before their name is published on the register?

The written direction will include information that the RSP’s name may be published on the public register.

SIRA may provide the RSP the opportunity to request that SIRA not publish certain information.

SIRA will consider any submissions when deciding what information to publish.

Appendix A

(Extract from the State Insurance and Care Governance Regulation 2021)

4A Relevant services—the Act, s26A

  • For the Act, section 26A, definition of relevant service, the following services are prescribed-
    • audiology and audiometry services
    • Chinese medicine services
    • chiropractic services
    • counselling services
    • dental services
    • dietetics and nutrition services
    • exercise physiology services
    • massage therapy services
    • medical radiation practice services
    • medical services
    • nursing services
    • occupational therapy services
    • optometry services
    • osteopathy services
    • patient transport services
    • pharmaceutical services
    • physiotherapy services
    • podiatry services
    • psychology services
    • rehabilitation services
    • social work services
    • speech therapy services
    • services provided to injured persons relating to the provision and maintenance of aids, appliances or prostheses, including the following-
      • artificial body parts or other artificial aids
      • aids for activities of daily living
      • mobility aids
      • equipment provided as part of treatment or therapy services.
    • domestic assistance services provided to injured persons, including household cleaning and laundry, lawn or garden care and transport services
    • private hospital and day surgery services, including in-patient and out-patient services,
    • workplace rehabilitation services
    • services provided by a health practitioner, not involving treatment, consisting of-
      • a medical opinion on the treatment or cause of an injury, or
      • an assessment of a permanent impairment, or
      • a peer review, or
      • facilitating discussions between an injured person and doctors, insurers, employers and other service providers to manage the rehabilitation of the injured person.
    • administrative services relating to the following-
      • referrals, including receiving referrals from or making referrals to, or on behalf of, a health practitioner
      • administrative functions associated with producing medical evidence relating to a person’s injury
      • functioning or impairment
      • access to medical documents, including medical certificates or radiology or medical imaging
      • centralisation or coordination of referrals or appointments and other administrative functions.
    • medication management and review, including the assessment and analysis of medication use, cost and prescriber behaviour.
  • Subsection (1)(zb) does not include administrative services relating to the provision of legal advice to, or representation of, an injured person regarding a claim or dispute under the workers compensation and motor accidents legislation.

Appendix B

List of documents to be complied with as part of compliance with section 1.2 d) of the Guidelines: i.e., an RSP is to comply with relevant provisions of the Guidelines, and relevant provisions of the workers compensation and motor accidents legislation and the regulations and guidelines made under those Acts.

For the purposes of section 1.2 d) of the Guidelines, this means the following:

Motor accidents legislation and the regulations and guidelines made under the Act:

Workers compensation legislation and the regulations and guidelines made under those Acts:

The following fees orders apply to specific relevant service providers providing relevant services in the workers compensation scheme:

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