Fraud Framework

Introduction

The State Insurance Regulatory Authority (SIRA) is the independent regulator of the NSW Workers Compensation System, NSW Compulsory Third Party (CTP) Scheme and the Home Building Compensation Scheme. These schemes provide an important social safety net for the people of NSW who may one day experience injury or loss.

As regulator of these NSW statutory insurance schemes, SIRA’s role is to ensure the schemes are fair, effective and affordable for all scheme users.

SIRA takes fraud against the schemes it regulates seriously and has a zero tolerance to fraud. SIRA is committed to the integrity of the schemes and will ensure it delivers on its functions by applying a comprehensive and systematic approach to the effective management of fraud in a way that ensures the viability of the schemes.

Purpose

SIRA’s Fraud Framework sets out the approach to deter, detect and respond to fraud. The framework aligns to SIRA’s Regulatory Framework and approach to being a contemporary regulator that is customer-centric, intelligence-led and risk-based.

Legislative framework

Cross government engagement

SIRA consults and works with other regulators and government agencies in its efforts to deter, detect and respond to fraud. These agencies include, but are not limited to the NSW Police Force, NSW Fair Trading, Transport for NSW, the Health Care Complaints Commission and the Australian Tax Office.

SIRA is committed to working with other agencies, where appropriate, to fulfill its legislative functions.

Fraud pillars

The Fraud Framework sets out some of the activities utilised to deter, detect and respond to fraud.

Deter

The main objective of the framework is to deter fraud from occurring within the schemes SIRA regulates. SIRA uses the following activities to deter fraud:

• Policy design
  SIRA considers the objects of the relevant scheme legislation and SIRA’s commitment to deter fraud in the development of scheme policy.
• Public education
  SIRA uses its website, social media and other communication resources as a mechanism to communicate to the community SIRA’s focus, activities and zero tolerance towards fraud.
• Publishing of prosecutions
  In line with its Regulatory Publishing Policy, SIRA publishes successful fraud prosecutions to ensure transparency, demonstrate SIRA’s accountability and increase public trust within the schemes.
• Health and related service providers - Publishing information
  SIRA must maintain a public register to enable the relevant communication to all stakeholders regarding practitioners who have been requested to take specific action or provide services in a certain way, had their practice limited, or been excluded from delivering services in the schemes SIRA regulates.
  
  Further information can be found on SIRA’s website.

Detect

Early detection of fraud is an essential element of fraud control. SIRA uses the following methods to detect fraud within the schemes it regulates:

• Tip-offs and reporting
  SIRA manages a confidential tip-off and reporting service which allows the public to anonymously report known or suspected fraud. The process for providing these reports or tip offs is published on the SIRA website. Tip offs may be received via email, mail or phone.
• Licensed insurer fraud forums
  SIRA convenes regular fraud forums with insurers to enable industry collaboration on fraud observations, insights and any identified systemic outliers within the schemes. This supports fraud detection and informs targeted responses and the tightening of fraud controls.
• Significant matter notifications
  A condition of an insurer's licence is to notify SIRA in writing of significant matters in accordance with the Significant Matter Notification Requirements. Any actual or alleged incidence of serious or systemic fraud against a scheme regulated by SIRA is considered a significant matter notifiable within 5 business days.
• Insights and analytics
  SIRA uses data available for the identification and analysis of data trends to test and help detect fraudulent activity within the schemes SIRA regulates. This program of work includes analytics on health provider behaviours and billing practices within the scheme.

Respond

SIRA will respond to fraud in line with its Regulatory Framework. This may include:

• Regulatory investigation
  SIRA has investigative powers under the relevant scheme legislation. SIRA carries out investigations within the Australian Government Investigation Standards. Investigations may start following tip-offs, data analytics, significant matter referrals, notifications of a systemic nature from scheme insurers, or referrals from other regulators and government agencies.
• Prosecutions
  SIRA may initiate fraud prosecutions under the scheme legislation or the Crimes Act 1900.
• External referral
  SIRA may refer matters to other relevant regulatory bodies to investigate or respond under their statutory functions and powers.