DIA Unpacks Reports of Fraud and Intra-Plan Inflation

Since our establishment, DIA has been at the forefront of driving quality within the NDIS Intermediaries sector, implementing standards above those set by the NDIA and NDIS Commission. We have called repeatedly on the NDIA and the NDIS Commission to adequately provide stewardship, monitor and regulate the sector, particularly with calls to close the conflict-of-interest loopholes, implement accreditation and independence of service provisions, all of which would have significantly reduced the opportunities for the types of issues that we are seeing occur today. The NDIA and NDIS Commission have ignored this advice repeatedly. Our members have collaborated tirelessly to implement standards when none existed.

DIA members have reported hundreds of suspected cases of fraud and misuse that have gone unanswered or only received basic acknowledgement of receipt.

Having clearly communicated DIA’s position on fraudulent and criminal practices as well as our support for these issues finally having the attention of the NDIA and NDIS Commission, the following is unpacking the inconsistencies that quality Support Coordinators and Plan Managers are being faced with from the recent communication. Nuance and accuracy in is key as blunt statements that don’t recognise the day-to-day critical work and environments only results in unintended consequences.

 

Current State of the Intermediary Sector

DIA reminds the NDIA and the NDIS Commission of the value that the Support Coordination and Plan Management workforce represent to the individuals on the NDIS scheme. For many years these professional services have been overlooked and unsupported by both the regulator and funding body, with little dedication to understanding the unique challenges this industry navigates being the interface between the NDIA and service providers to ensure NDIS Participants have support on their side and with their interests placed above all others.

The recently released statements and letters attributing failures of quality and regulation have created an unacceptable level of anxiety for participants, quality Support Coordinators and Plan Managers alike. The messaging creates a sense of ‘guilt by association’ warning all intermediaries against alleged criminal and criminal networks type behaviours, and raising the responsibility of scheme regulation to previously unforeseen levels. DIA cautions The NDIA and its regulator about statements that draw direct conflict to its own established policies and directions regarding the role of Support Coordinators and Plan Managers. The distress and confusion this creates for an already exhausted sector is likely to result in further challenges experience by vulnerable participants, and a depletion of a dedicated workforce previously committed to supporting them.

DIA continues its call on the Minister for the NDIS, the Department of Social Services, the NDIA and the NDIS Commission to work in partnership with DIA to improve quality and participant experience and not weaken the resolve of quality Support Coordinators and Plan Managers.

More than 30% of the over 38,000 Intermediary workforces are people with lived experience of disability. Some work for larger organisations and other who have developed small businesses with their community.

These statements and letters continue in a long series of examples where DIA might agree with the intent of communication released, however clumsy and contradictory language creates more questions, anxiety, depression and concern for participants, quality Support Coordinators and Plan Managers and their workers than it needs to.

 

Understanding Support Coordination

Quality Support Coordinators are tasked with navigating the multiple service systems for NDIS Participants with the most complex support needs. The NDIS Review recognised that Support Coordinators are underfunded with inadequate access to NDIA systems and processes. Quality Support Coordinators use their knowledge and skills to genuinely support the needs of their participants and their families, untangling complex rules and barriers to prevent crisis or deterioration in persons wellbeing. They are one of the few supports that is answerable to the participant for the services they provide, elevating the Participants interests above all others.

Almost half of all NDIS Participants (46%) are funded with Support Coordination at different levels. there are three different levels of Support Coordination, aligned to the complexity of a participant’s circumstance. The possible functions that a Support Coordinator might undertake include supporting a Participant to:

• Understand their NDIS Plan
• Connect with Supports and Services
• Design Support Approaches
• Establish and Maintain Supports
• Coach and Mentor, Refine and Reflect
• Support interaction with Targeted Interfaces (such as housing, health, child protection, mental health, education systems, employment supports, transport, justice etc).
• Crisis Planning, prevention, mitigation and action
• Address complex barriers
• Build and Re-Build complex support solutions and service plans
• Build and Maintain Capacity and Resilience
• Report to the NDIA

The work required of Support Coordinators from the above list is heavily influenced by the funding allocation provided to a participant in their Support Coordination budget. This is important as it means that all statements like “Support Coordinators must do X” or “Support Coordinator have an important role to do Y” comes with the limitations placed on them by what is achievable based on the determination of the original planning decision.

In simple terms, if a Participant is funded for 10 Hours of Support Coordination, they would likely only be able to be supported with 1 to 2 of the above function, and these 10 hours are used on tasks directed by the participant, not the NDIA.

The statement released ahead of the letter spoke of intra-plan inflation and stated 25,000 participants 90% of these received Support Coordination services. Support Coordination, by its very nature, is only made available by the NDIA to those individuals on the NDIS that are expected to need additional support because of the complexities in their circumstance. So, it’s not surprising to see these 25,000 participants receive an increase to their plans of almost $82,000 or 4.4 times the median NDIS payment per participant in 2024. This indicates that these are likely participants with significantly more complex support needs so to draw the conclusion that it is the Support Coordinators driving the inflation rather than the condition of the participant is an error in judgement. There is also a higher number of these participants are funded for support independent living supports (SIL) which has long been a driver for intra-plan and inter-plan inflation.

The subsequent letter to Support Coordinators appears to not have gone to all current active Support Coordinators which has many in the sector wondering what the criteria was to receive such a letter.

The letter issued by the NDIA and NDIS Commission states that “Support Coordinators should not allow plans to run down before seeking a plan assessment”. The NDIA’s own Supported Decision-Making Policy clearly states that Support Coordinators are not substitute or legal decision makers of a NDIS Participants. A Support Coordinator can only provide advice and information regarding available services and supports, and what can be afforded within their allocated budget. A Support Coordinator does not have the authority or delegation to unilaterally allow or not allow a plan to be spent in a certain manner, that remains in the control of the NDIS Participant, their Nominee, Guardian or Legal Decision maker.

This is the first time the NDIA and NDIS Commission have used such language. DIA is concerned if this statement is read on face value, it could set unrealistic and inaccurate expectations on the role of Support Coordinators.

From as early as June 2022 the NDIA has stated that “We generally won’t change your plan if you want more funding because you’ve used all the funding in the plan, or you want the same supports others have received”. In fact, it’s on the front page of the form used to lodge a Change of Circumstance.

Whist this is accepted and is paraphrased in the letter sent to Support Coordinators; a NDIS Participant having spent their NDIS funds ahead of the planned reassessment date should trigger a reflection on why the plan didn’t meet the participant’s needs for the projected time period.

Was this ‘reckless’ spending, or was the initial plan not fit for purpose? The resounding absence of accountability on the role of planners to produce a quality plan that meets the needs of Participants is disappointing. Though evidence is always required to justify a Reassessment, Change of Circumstance, and build a plan; DIA’s data and repeated reports from our members show far too many examples of where expert reports and evidence go unread, not considered or are rejected (queue the collective sigh of quality Support Coordinators and quality Allied Health Professionals).

Of late, the more common challenge in adequate plan building is the advent of plan-rollovers / extensions to remediate workforce planning and new PACE business system introduction failures. Currently the NDIA is not on-top of their access and planning workload, new plans are being created without reviewing the current and actual needs of participants. DIA has seen hundreds of examples where Participants have gone years without having a plan built around their actual and current circumstances. This has resulted in artificially inflated Change of Circumstances and Intra-Plan Inflation statistics. For example, a child who has become an adult may need significantly more support to live independently, yet because of multiple rollovers/extensions continues to have inadequate funding.

NDIS Participants and quality Support Coordinators are consistently told mixed and conflicting messages when it comes to plan spend. Advice from NDIA Planners and LACs state that Change of Circumstances applications will not be reviewed until a Participant’s plan is approaching depletion. Participants are encouraged to use their funds flexibly so that they don’t need to undertake early plan review until it is absolutely necessary. Support Coordinators are also advised that they must ‘get on the front foot’ and notify the NDIA if a participant’s NDIS plan no longer aligns to the Participants disability support needs so plan funds don’t run out, but little timely advice is provided to Support Coordinators or Participants to manage the expectations of how long this process of review will take, DIA has heard of examples of Change of Circumstances processes taking longer than 6 months. Inevitably, the funds run out and the Participant is put at risk.

A quality Support Coordinator can reshape and redirect funding to the most pressing areas within Scheme rules, but if the NDIS plan is built on circumstances that no longer exist, then there is an ever-increasing likelihood that the plan will not meet the needs of the NDIS Participant.

To meet the access criteria to join the NDIS, a person with a disability must be able to demonstrate that their disability is permanent and significant, however the environment a person lives in and their goals does not have to be. As long as the NDIS is committed to being a person-centred insurance scheme that relies upon contributions from other places (paid and unpaid) and responds to big changes in a person’s life circumstance – then changes in expenditure will happen.

 

Understanding Plan Management

Plan Managers are to the NDIS as Tax Agents/Accountants are to the ATO. Plan Managers support NDIS Participants to lodge claims from the NDIA and then disperse the funds of those claims to providers that have delivered the services NDIS Participants have used. Plan Managers also support participants to monitor and track their spending against their NDIS Plan. More often than not quality Plan Managers are one of the few supports that is actually on the side of the Participant, putting the Participants interest above all other, particularly where a Participant is supported by an LAC. Similar roles can also be found in Aged Care and other social service schemes.

Plan Management is the most popular management option with 63% of all NDIS Participants making the decision to use a Plan Manager, because it gives them the greatest empowerment to exercise choice and control over their plans, budgets and providers. The popularity of Plan Management reflects the positive difference that quality Plan Managers make to overcome the complexity, bureaucracy, and compliance requirements of the NDIS so participants can get on with living their lives.

Plan Management is one of only three disability supports where providers must be registered with the NDIS Commission, and the only disability support where this requirement is enshrined in legislation.
DIA has been calling for the NDIA to provide clear guidance on evidence required to support submitted claims for each NDIS line item, however the NDIA has failed to act.

The NDIA holds all funds in a NDIS Participants’ plan until a claim is lodged for a delivered service by a NDIS Participant or on their behalf by a Plan Manager. The NDIA is just like any other insurance company in that way, you lodge a claim and if the claim is accepted the funds are released. When a Plan Manager lodges a claim on behalf of a participant, they are required to provide information including the line item being claimed, date of service provided, the ABN of the support provider and a range of other information.

The NDIA SAP System and PACE, its replacement currently being rolled out, are riddled with bugs, errors, issues, and limited capability which have reportedly allowed unscrupulous operators to commit the alleged offences described in The Australian article. DIA encourages the NDIA to implement an efficient business system that has technical controls and capability that prevents fraudulent, mistaken and/or non-compliant claims from being accepted and processed.

At the end of March 2024, there were 408,702 participants that Plan Manage their supports. The 90% of the 25,000 ‘overspending participants’ referenced in this article is 5.5% of all participants that Plan Manage their funding. The 3,500 in the article is 0.8% of all participants that Plan Manage their funding.

Well over 90% of the NDIS Participants who engage a Plan Manager do so from approximately 500 Plan Managers, with over 40% of Participants being serviced by approximately 10 Plan Managers. DIA suspects that the alleged 343 operators likely fall outside of both of these cohorts. This means the overwhelming majority of the 408,702 NDIS Participants that engage a Plan Manger receive services from quality Plan Managers enjoying reliable, timely and accurate service that delivers choice and control and participant self-direction.

The NDIA and the NDIS Commission have stewardship, safeguarding and regulatory obligations over the sector; DIA has to ask – how did these two Commonwealth bodies allow such unscrupulous players to become registered providers and claim taxpayer funds without detecting this fraud until now?

Over the past two financial years, quality Plan Managers have filtered out around $1.8bn in non-compliant claims from being lodged with the NDIA ($600m in 2021-22 and $1.3bn in 2022-23), supporting NDIS Participants and the Australian taxpayer. DIA anticipates around a further $2bn in non-compliant claims being filtered out by Plan Managers by the end of the current financial year.

The joint letter from the NDIA and NDIS Commission sent to Plan Managers included a statement that “Plan Managers like you are responsible for how, where and when NDIS participants spend their plans”. This is the first time the NDIA and NDIS Commission have used such language. DIA is concerned if this statement is taken at face value, it will set an unrealistic and inaccurate expectation on the role of Plan Management. To that end, DIA will seek specialist legal advice on the matter as the statement on initial reading appears to be inconsistent with the current of the role of a Plan Manager.

DIA receives daily reports from quality Plan Managers indicating that they have parted ways with a Participant because they would not process a non-compliant invoice, only to see the participant end up down the road at a dodgy service that will process anything no questions asked. These long-tail dodgy market operators would not exist in the sector if the NDIA and NDIS Commission had implemented DIA’s Professional Standards of Practice.

Quality Plan Managers operate in a complex and difficult environment where rules and guidance contradict themselves, and where simple sentences are taken out of context resulting in perverse outcomes. Nuance, clarity and accuracy in language is critical in the current environment.

Effective and quality Plan Management makes for a better experience for the participant living with disability and saves the scheme money through increased efficiency and compliance with scheme rules.

So far in this financial year, Plan Managers have supported NDIS Participants to claim over $22bn in funded supports and services from their plans that they need to live their lives. For this service plan managers are paid $100 per month for each participant they support, or just 2.37% of the funds they support a NDIS Participant to claim. In simple terms Quality Plan Managers are delivering high level of individualised NDIS financial navigation support at an extraordinary low rate akin to credit card transaction fees.

We note that in an environment of cost-of-living crisis, supercharged inflation, rising business costs like wages, insurance and rent, Plan Managers prices have been frozen for 4 years with no relief in sight.

 

Understanding Intra-Plan Inflation

Intra-plan inflation is jargon that the NDIA uses to describe when a Participant has expended their funds or is likely to expend their funds ahead of the current plan period and has to lodge a form to change their funding; this is called a Change of Circumstance. NDIS plans are extremely rigid and do not include room to meet the needs of a person with a disability when their needs change. In line unexpected things happen and when they do people need more support before the end of their plan. There are several factors that drive Intra-Plan Inflation which include:

• Change of support needs.
• Poor quality of the initial plan. This is where the NDIA got the initial plan decision wrong and did not include adequate funding. DIA sees far too many examples of where expert reports and evidence go unread, not considered or are rejected by the NDIA.
• Multiple plan rollovers or extensions, where a Participants current support needs are not adequately assessed.
• Crisis event where emergency funding is needed.
• Where a participant tries a new or innovative support to achieve their goals and outcomes and it doesn’t work. This is not unexpected and part of living with disability but as NDIS Plan are so ridged there is not the room to try new or innovative things

Without diminishing or downplaying the very real fraud issues, as above. We have to be clear about the levels of intra-plan inflation and what those drivers are. The NDIA’s statement indicates that:

• 21,500 NDIS Participants requested $1.246bn in addition plan funding or an average of more than $57,000 per participant or 3.1 times the median NDIS payment per participant in 2024.
• 3,500 NDIS Participants requested $818m in addition plan funding or an average of almost $234,000 per participant or 17.6 times the median NDIS payment per participant in 2024.

This indicates that these are likely participants with significantly more complex support needs and thus more likely to need more frequent adjustments to NDIS Plan Funding. It is also highly likely that some of these participants would be funded with independent living supports (SIL) which has long been a driver for intra-plan and inter-plan inflation.

This analysis is not intended to downplay any role that alleged fraud might play in these numbers. Rather highlight that it is unlikely that items such as Bird Seed, Tv Antennas and other items in the statement are of significant driver in this cohort of intra-plan inflation.

Again, DIA does not downplay the role that claiming of non-compliant supports has on intra-plan inflation rather we would propose that the major contributing factor in intra-plan inflation of this cohort is largely due to a difference in what volumes and ratios of support (namely SIL and Support Workers) are funded with in a participants plan, verses how the participant is expending these funds.

Given the significant size in value of the requests being sort by these Participants, they would have had to demonstrate significant evidence to justify their Change of Circumstance request, as without it the NDIA would have likely rejected the request.

Intra-Plan inflation is complex, it moves based on NDIA operational performance, policy positions and it has an interconnected relationship with both inter-plan inflation and indexation. Below is a figure from the latest NDIA Quarterly report which shows Intra-Plan inflation is at a 2 and a half year low (10 Quarters) at 5.7% and significantly down from a 9.7% peak in June 2020.

‘Automatic Top-Ups’

There is no such thing as ‘Top-Ups’ automatic or otherwise in the NDIS. There are only four ways for a Participant can receive a change in their NDIS funding:

• Wait for their next plan re-assessment (plan review).
• Lodge a Change of Circumstance, if the NDIA accepts this request, it essentially triggers an early plan re-assessment (plan review).
• Request the NDIA undertake a plan variation, this is mainly used to correct small or technical errors in the plan, change a reassessment date or change a plan management type etc.
• If a claim is automatically rejected by the NDIA for some reason, a Participant, Provider or Plan Manager (depending on the management type of those funds) can lodge a Manual Payment Request where the NDIA can review the claim manually to see if it aligns with the original Reasonable and Necessary decision of the plan, in some cases this may see the NDIA re-allocate funding in line with the original plan reasonable and necessary decision.

Each of the above are defined processes where the NDIA makes a decision under the NDIS Act to accept or reject such requests to change the funding in a Plan. These processes require evidence and paperwork to be provided. A participant cannot simply just call the NDIA and say, “hey, can you put some extra funds in my plan, I ran out”. That’s not how it works. Nor should the NDIA accuse quality Plan Managers and Support Coordinators for driving intra-plan inflation and try and blame them for supporting participants directions to help lodge compliant paperwork when the participant choses to make a request for a change to their NDIS funding.

 

Conclusion

DIA has no tolerance for scammers, criminals, fraudsters or rogue operators. Quality Plan Managers and Support Coordinators that represent the best interests of participants should not need to compete with these allegedly unethical and criminal entities. DIA is pleased to see the NDIA and the NDIS Commission finally taking action. They must be investigated, prosecuted and, if found guilty, barred from the NDIS.

Quality Plan Managers and Support Coordinators have always collaborated with each other, delivering significant support to NDIS Participants with a unique combination of skills and experience. It is clear that now more than ever we need to come together as a group to ensure that NDIS Participants enjoy quality supports, choice and control, dignity of risk and the right to self-determination that will enable them to achieve their goals and live an ordinary life.

Intra-plan inflation is complex and should not be boiled down to simple ‘miss-management’ and the fault of intermediaries, particularly given the review and approval roles the NDIA play.

DIA continues its call on the Minister for the NDIS, the Department of Social Services, the NDIA and the NDIS Commission to work in partnership with DIA to improve quality, participant experience, choice and control and self-determination and not weaken the commitment of dedicated and quality focused Support Coordinators and Plan Managers.