Everything you need to know about NDIS payment integrity audits

The Australian Government has always taken a firm stance on fraud and non-compliance in the National Disability Insurance Scheme (NDIS) – and with the multi-agency Fraud Fusion Taskforce (FFT) investigating billions of dollars of payments made to NDIS providers, the focus on integrity has never been sharper.

Formed in late 2022, the FFT is co-led by the National Disability Insurance Agency (NDIA) and Services Australia, and has a raft of other member agencies, including the Australian Federal Police and the Australian Taxation Office. The Taskforce works to prevent and disrupt fraud against government programs – like the NDIS – and includes intelligence sharing, prosecution and other regulatory actions.

With safeguarding of participants, their funding, and the Scheme at the centre of the NDIA’s remit, the Agency has become increasingly vigilant when it comes to the conduct of NDIS providers.

To ensure people with disability can continue to access the vital supports they need, the NDIA has in place a number of compliance tools and guardrails that not only protect participants but also maintain the integrity of the Scheme.

Enter the payment integrity audit, designed to change behaviour in the NDIS by scrutinising claims and making providers accountable for the invoices they submit.

What’s a payment integrity audit?

One of many tools in the NDIA’s fraud and non-compliance toolkit, a payment integrity audit is – in essence – a request from the Agency for more information about a claim.

It’s important that NDIS funding isn’t misused and it’s a legal requirement that it’s spent in accordance with participant plans, so the NDIA is increasingly using payment integrity audits to:

• check providers have claimed correctly, delivered the supports they’ve claimed for, and adhered to the NDIS Pricing Arrangements and Price Limits
• help prevent fraud and/or the misuse of NDIS funding

The Agency audits claims submitted by both registered and non-registered providers for supports provided to self managed, plan managed and Agency managed participants. The vast majority of audits take place before a claim is paid, but occasionally the NDIA investigates post payment.

How do payment integrity audits work?

When an invoice is submitted to the NDIA, the Agency’s systems run automated checks that look at key data points in a claim. Based on the information identified through those checks, the NDIA may ask a provider, a plan manager or both to provide more information to substantiate the claim.

The NDIS Act provides the Agency with powers to obtain information, recover debts, and bring legal proceeding against providers for non-compliance. In addition to denying a claim before it’s paid, the NDIA can continue to review future claims.

Payment integrity audits are conducted by a dedicated team at the NDIA – not by planners or local area coordinators – and current areas of focus include claims related to Short Term Accommodation, Supported Independent Living, support coordination, and some allied health supports.

As part of a payment integrity audit, the Agency checks flagged invoices and asks providers to substantiate their claims by providing some or all of the information below:

• service agreements
• evidence of supports delivered (e.g. case notes)
• rosters
• timesheets
• travel logs
• past invoices
• evidence of why supports were delivered, whether they were intended to build participant capacity, and/or how they were deemed to represent value for money
• Australian Prudential Regulation Authority (APRA) numbers and/or other provider qualifications

There’s no doubt that audits can be time consuming for providers, so it’s best to act quickly.

What happens if you’re audited?

It’s your responsibility to act within the Agency’s requirements.

If your client is plan managed by us and the NDIA lets us know it’s auditing one of your claims, we’ll contact you and our experts will act swiftly to provide the Agency with the information it needs to complete its audit.

If the NDIA needs information we don’t hold – like rosters and timesheets – Agency staff will get in touch with you directly.

Typically, you’ll receive a request for information email from the NDIA which includes an explanation of what’s being audited and a reference number. If you’re notified that one of your claims is being audited, gather all available evidence to support the claim and provide it to the Agency as swiftly as possible. If you need more time, you can ask the NDIA to extend its deadline.

Once it has all requested information in hand, the Agency will consider the matter and make a decision. If it’s satisfied, it'll add the claim to the next payment run and let us know when it will be paid – and we’ll communicate that to you. If it isn’t satisfied, the NDIA may reject your claim.

The timeframe of audits is up to the Agency, so if you're awaiting an outcome and want to know what’s going on with the process, it's best to contact the NDIA directly.

Control what you can

When it comes to compliance, the best line of defense is to have your paperwork in order so you can clearly and accurately substantiate every NDIS claim.

Keep vital records, registrations and qualifications up to date, make sure to have service agreements in place with your clients, and review your invoices before submitting them for payment so you know they include all required information. Compliant invoices should include:

• a unique invoice number
• the participant’s full legal name
• the participant’s NDIS number
• the date/s of service/s provided
• a detailed description of each service provided, including the line item code and the quantity of support/hours delivered
• the price or hourly rate charged
• your contact information – email address, street address and phone number
• your ABN
• your bank details (account name, BSB and account number)

Before providing supports, check that your client has the necessary funding – in the correct funding categories – and ask them to email us a copy of the service agreement they have with you so you and they can be sure the funding is there when it comes time to claim.

My Plan Manager’s market-leading technology supports us to conduct payment integrity checks, ensure correct use of client funds, and enforce the NDIS Pricing Arrangements and Price Limits.

Every claim we receive undergoes 30+ automated checks to ensure it’s compliant with NDIA requirements, and that’s a great start when it comes to audits!

What not to do

Don’t be lax about record keeping, be accurate, and be sure to have your paperwork in order, because the NDIA may request documentation before or after payments are made if it needs more information to substantiate a claim. These requests can be made randomly, so vigilance is key.

The Agency says that re-submitting a claim that’s been held for review is non-compliant behaviour – and resubmitting it within 14 days of the initial claim being made may trigger an even deeper review.

We understand there are times when duplicate claims are submitted by mistake, and if we spot one, we’ll flag it with you and let you know why it can’t be paid.

Reporting fraud and non-compliance in the NDIS

The aim of the FFT is to disrupt bad practice and fraudulent providers and it’s reportedly received tens of thousands of tip-offs since it was formed.

If you suspect someone is doing the wrong thing with NDIS funds, you can report your concerns. Find out how by clicking here.

We’re here to help

If you have any questions about payment integrity audits, our friendly team is here to assist. You can call us on 1800 608 298 from 8am-5.30pm (SA time), Monday to Friday.