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Allied Health Funding: Do Professional Recommendations Actually Matter?

We all know that the NDIA often disregards professional recommendations about how much allied health funding a person should receive, but can they really do that? Sara dives into an Administrative Appeals Tribunal case that covers this very issue.

By Sara Gingold

Updated 15 Apr 202412 Nov 2019

It’s a tale as old as the NDIS itself. An allied health professional recommends that a Participant receive a certain number of therapy hours but in the plan review, the NDIA or LAC responds that they will only fund a fraction of that amount. If the Participant takes it to review, they might be able to win some form of compromise. But not everyone is up for the fight. Many people will just accept what they are offered, regardless of how it corresponds to their goals or needs.

So what is the deal with the NDIA rejecting professional recommendations? Given the experience, qualifications and personal knowledge of the Participant that allied health professionals have, it would seem logical that the NDIA accept their recommendation as a default. As a minimum, you’d expect that there would be a guideline about when the NDIA can disregard this advice.

Alas, in the public domain at least, there is very little information available. The Operational Guideline on Planning is conveniently silent on how much stock the NDIA should put into the recommendation of allied health professionals. There is a lot of talk about the NDIA requesting evidence and assessments, but very little on how they will use them.

This was the central issue of a recent Administrative Appeals Tribunal (AAT) case- JC v NDIA. JC is a young man with multiple significant disabilities who requires intensive allied health interventions due to his complex behavioural support needs and limited communication. JC’s speech therapist recommended 80 hours of funding for speech therapy, and his occupational therapist (OT) recommended 63 hours. In total, JC was asking for 143 hours of allied health intervention per year.

Now, I know what you’re thinking- that seems like an awful lot of therapy. But JC’s team had detailed their reasons for the hefty request. For one thing, they were working towards the goals of supporting JC to transition to independent living and to have positive interactions in the community. Neither of these aspirations could be achieved without significant investment. Moreover, JC’s therapists also gave evidence that they were only able to work with him directly when his arousal levels were in the “green zone.” So about half of all sessions were instead spent training his support team.  

By the time the case reached hearing, the NDIA was willing to fund 100 hours of allied health therapy and 100 hours with therapy assistants (which none of the allied health team had recommended). Broadly speaking, the Agency gave four main reasons for rejecting the therapists’ recommendations:

  • The allied health professionals were both new to JC’s support team. The OT had only seen him 10-20 times before making her recommendation, and the speech therapist had only met him 7 times.
  • The Agency claimed that the Participant’s mother unduly influenced both therapists in reaching their recommendations. They also felt that the therapists put too much stock in copying what past allied health professionals had done before them.
  • Both the OT and speech pathologist had not read the Participant’s entire Behavioural Assessment Report (BAR) before making their recommendations.
  • The NDIA also had various issues with the quality of the speech pathologist’s report.

But as the Tribunal pointed out, the NDIA’s expert witness, who manages their National Technical Advisory & Complaints Branch, admitted that she had never even met the Participant. Which makes the NDIA’s criticism of the amount of time the therapists had spent with JC frankly bizarre. She was also not an allied health professional, so it was not clear on what grounds she was criticising the speech pathologist’s report, or making alternative recommendations. All this led to this entertaining pronouncement by the AAT:

“The Tribunal prefers the evidence of Ms [C], Ms [G] and Ms [K], as they are each qualified and practising therapists who have met and interacted with [JC] and his carers. There are better placed to make recommendations as to his need given that they were in a position to undertake a professional assessment of him. There is evidence that each of them have at least a reasonable understanding of his therapeutic history. Accordingly, the Tribunal is not prepared to dismiss Ms [C]’s and Ms [G]’s recommendations for the reasons contended by the NDIA, in preference for Ms [P]’s recommendations.” 

Believe it or not, that is about the closest AAT rulings come to humour.

Importantly, the Tribunal also felt that it was entirely appropriate for JC’s allied health professionals to consult with his mother and past therapists before making their recommendations. Indeed, this was described as “prudent professional practice.” The Tribunal did acknowledge that they would have felt more comfortable if the therapists had read the whole Behavioural Assessment Report. However, it was noted that it is a lengthy document and that both allied health professionals had read key sections.

Overall, the case provides great ammunition for anyone who wants to challenge their allied health funding. The Tribunal basically encouraged the Agency that they had to listen to professional recommendations. However, the judgement does not give a lot of insight into the reasoning or process behind why the NDIA was rejecting these recommendations in the first place. Nor are we necessarily much the wiser about why this practice is occurring on such a large scale.

The judgement does make reference to an internal document that is meant to provide guidance for Planners, LACs and delegates working with people with complex behavioural support needs. Produced in 2016, it is called Practice Guide- Intensive Super Intensive Participants (their document naming team must have been having a rough day). A redacted version is available through FOI request. The document has a table that lists a potential support items for Participants with complex behaviour support needs, with a column marked “benchmark hours.” This is just speculation- but could the allied health recommendations that are being rejected be the ones that fall outside of these benchmark hours? But as anyone who has had any experience with FOI requests will have already guessed, the recommended hours were of course all redacted. Naturally, it is entirely possible that behind those bulky blacked out lines it just says, “refer to the reasonable and necessary criteria.”  But my money is on there actually being, as was promised, “recommended hours.”  

It is important to acknowledge that the NDIA’s suspicion of allied health recommendations is not completely unjustified. In most cases, the therapist who is writing the recommendations will be the one delivering the services. So there is often a clear business incentive for upping the hours. As was alluded to in the JC case, there may also be a temptation to keep the Participant and their family (who are the purchasing customers) happy by requesting the amount of hours that they are seeking. However, should doubting the ability of allied health professionals to put the Participant’s interests before their own really be the default position of the NDIA? It seems pretty cynical, and not exactly conducive to market growth.

There are more gems in the JC case which we have not covered in this article. You can check out VALID’s great summary of the case here. With any luck, the case will be enough to put pressure on the NDIA to develop a comprehensive, publicly available policy on how they respond to allied health recommendations. But don’t hold your breath while we wait.  

Authors

Sara Gingold

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