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Ask DSC: Is this fraud?

This week, a Plan Managed participant wants to access a support that costs more than the price limits. Can the provider bill for more hours to make up for the rate difference?

By Rob Woolley

Updated 15 Apr 202416 Nov 2022

I'm a sole trader who provides life skills training for participants moving out of home for the first time. Because of the skilled and intensive nature of the support I provide (and the qualifications I have), I charge above price guide rates. NDIS work is a very small part of what I do. To date, this has not been a problem as all the people I support are self managed.

However, I have recently been asked to support a young man who is plan managed, and the Plan Manager insists I stick to the price limits in the price guide. If I did this, I wouldn’t be able to support him. The young man asked if we could just charge for more hours to make up the rate difference, but is this the right thing to do? And could there be legal ramifications? I just want to do the right thing, and I am not an expert in the NDIS rules! This would be the only way he could access my services.

 

Thanks for your question – you’ve got a juicy one here! It’s great that you want to do the right thing, so I feel comfortable telling you that what he is asking you to do is fraud. Not diet fraud, not fraud lite, not mini-fraud, but full-on, flat-out fraud. Sorry, champ; there are a few factors involved so let’s break them all down.

You’re right that when you’re working with self-managed participants, you don’t have to stick to the pricing caps and rules outlined in the NDIS Pricing Arrangements. Keep in mind that you do still have other obligations, whether you’re registered or unregistered.

The Plan Manager is also correct that when services are billed through them, the caps and rules in the NDIS Pricing Arrangements must be followed. This means that if you send a bill with an hourly rate above the pricing cap, the claim will be rejected. This isn’t good for the Plan Manager or you or the participant.

And this is where things take a turn. It sounds like the young man is asking you to invoice for, say, four hours of support when you’ve only delivered two hours. That way the total rate equals what you usually charge and, on paper at least, the claim stays within the pricing cap. The person probably doesn’t realise that by asking you to fudge your invoices in this way, they are asking you to commit fraud. The NDIA page on Fraud and Non-Compliance puts this example outside creative use of funds and firmly in the “dishonest behaviour” category.

Not so many years ago, this used to be a somewhat common practice by some providers and participants or family members. It was seen as a way of exercising choice and control, and many Plan Managers were willing to go along, as the rules set out by the NDIA were less clear. But times have changed, and what the person is describing is clearly not allowed. Unfortunately for us all, it’s not 2017 anymore.

In terms of whether this behaviour is ethical, that’s a question for the philosophers of the world. It could be argued that if you are doing this with the participant’s informed permission, you are helping them to exercise choice and control and get the best outcome from their plan. However, NDIS definitions of fraud don’t have quite so many shades of grey, and the Compliance Response Team aren’t known for its willingness to engaging in winding conversations about ethics and morals over lazy Sunday brunches.

So, in answer to your question: no, this isn’t the right thing to do per the NDIA rules and, yes, there could be ramifications for those involved. We would advise you not to submit a fraudulent invoice.

Choice and control can still be enabled: one option is that the person could be supported to self-manage the relevant part of the plan so they can pay you above the price cap, or you could try to find a line item in the pricing arrangements that more closely aligns with your billable rate (maybe a capacity building support?). It’s definitely worth a conversation with the person to explore the options for going forward.

Good luck!

Authors

Rob Woolley

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