The National Disability Insurance Scheme (NDIS) is an essential program that supports Australians with disabilities, ensuring they receive the necessary care and services to live a more independent and fulfilled life. As a registered NDIS provider, Trusted Care & Support Services is committed to adhering to the rules and guidelines set by the NDIS to ensure that our participants receive the highest standard of care. In this blog post, we will delve into the general claiming rules and the importance of service agreements.
General Claiming Rules
Registered NDIS providers, including Trusted Care & Support Services, can only claim payment for supports once they have delivered or provided the support. This ensures that participants only pay for services they receive, fostering trust and transparency in service delivery.
Where price limits apply to support, prices charged to participants must not exceed the price limit prescribed for that support in the NDIS Pricing Arrangements and Price Limits. This regulation is crucial as it protects participants from being overcharged and ensures that services remain affordable and accessible.
Providers are responsible for ensuring that claims for payment accurately reflect the supports delivered, including the frequency, volume, and type of support. This responsibility ensures that participants receive the services they need and that providers maintain integrity in their billing practices. Claims need to be made against the specific support item that aligns with the service delivered. This alignment is crucial for maintaining the accuracy and transparency of the billing process.
Falsifying claims for payment is a serious compliance issue and may result in action against the provider. Such actions can include penalties or loss of registration, highlighting the importance of honesty and integrity in all dealings. Providers are also required to keep accurate records of claims, which are subject to audit. Maintaining detailed records ensures that providers can substantiate their claims and remain compliant with NDIS guidelines.
Service Agreements
A Service Agreement is a formal agreement between a participant and a provider. This document is crucial as it helps to ensure that there is a shared understanding of:
- Expectations of what supports will be delivered and how they will be delivered: Clear expectations help prevent misunderstandings and ensure that participants receive the care they need in the manner they expect.
- The respective responsibilities and obligations of the provider and the participant and how to resolve any problems that may arise: Knowing each party’s responsibilities ensures smooth service delivery and provides a framework for addressing any issues that may occur.
Service Agreements should be simple and set out how and when supports will be delivered. They can include information such as:
- What supports and services the provider has agreed to provide: This section outlines the specific services the participant will receive, ensuring clarity and mutual understanding.
- The prices of those supports and services: Transparent pricing helps participants understand the cost of their care and ensures they are not overcharged.
- How, when, and where the supports and services are provided: Detailed scheduling and location information helps participants plan their care and ensures they receive services at convenient times and places.
- The duration of the Service Agreement and when and how the Agreement will be reviewed: Specifying the agreement’s duration and review process ensures that it remains relevant and effective over time.
- How the participant or the provider may change or end the Service Agreement: This information provides flexibility and ensures that both parties can adapt the agreement as needed.
- How any problems or issues that may arise will be handled: Having a clear process for addressing issues helps resolve conflicts quickly and effectively.
- Participant responsibilities under the Service Agreement: Knowing their responsibilities helps participants engage actively in their care and contributes to a successful service delivery.
- Provider responsibilities under the Service Agreement: Clearly outlining provider responsibilities ensures accountability and high-quality service delivery.
Providers should not seek to impose conditions on participants through Service Agreements that are not in line with those set out in the NDIS Pricing Arrangements and Price Limits and its associated documents. This adherence ensures that participants are treated fairly and that agreements are consistent with NDIS guidelines.
Claiming for Support Items
The NDIS framework includes various rules for claiming support items, depending on whether they are subject to quotation, have a price limit, or do not have a price limit. Understanding these distinctions is crucial for both providers and participants to ensure proper billing and compliance.
Claiming for Support Items that are Subject to Quotation
Providers can only claim for a support item that is subject to quotation from a participant’s plan if they provided a quotation to the NDIA for the support item and it is a stated item in the participant’s plan. When the NDIA approves a quote, it will create a service booking for the support item that the provider can use for claiming purposes.
This process ensures that both parties agree on the cost and specifics of the service beforehand, leading to more accurate and transparent billing.
Claiming for Support Items that Have a Price Limit
Where a support item has a price limit, the provider cannot agree on a price for the support with the participant that is greater than the price limit. Claims should be made in the units specified for the item and at the agreed unit price, which must not be higher than the applicable price limit.
For example, if a provider has agreed to deliver a support to a participant at an hourly rate of $50 and provides support for 30 minutes, they should make a claim for 0.5 hours at the agreed unit price of $50. They should not claim for 1 unit at $25. This ensures that billing remains consistent with the agreed terms and avoids overcharging.
Claiming for Support Items that Do Not Have a Price Limit
Where a support item does not have a price limit, the provider and participant should agree on the reasonable price for the support. If necessary, they should also agree on the billing schedule for the support. For example, they might agree that a support should be claimed weekly. These claims are subject to the general claiming rules, including that supports can only be claimed for after they have been delivered.
Providers should claim for that item by reference to the “notional unit price” if there is one set out in the NDIS Support Catalogue or the NDIS Assistive Technology, Home Modifications and Consumables Code Guide.
For instance:
- Example – Claiming for Low Cost AT: A provider has agreed to deliver a text player to a participant at a cost of $530. The relevant support item (03_220300911_0113_1_1: Low Cost AT for Vision Related AT) is not subject to a price limit but has a “notional” unit price of $1.00. The provider would submit a payment request for 530 units at $1.00 a unit for a total amount of $530.
- Example – Claiming for Activity-Based Transport: Activity-based transport support items are not subject to price limits but have a “notional” unit limit of $1.00. If the non-labour costs of the activity-based transport was $21.50 (as in the example support item 04_590_0125_6_1), the provider would submit a payment request for 21.5 units at $1.00 a unit for a total cost of $21.50.
Time of Day and Day of Week
In determining which price limit is applicable to a support, the important consideration is when the support is provided to the participant, not the shift of the worker used to deliver that support as determined by the applicable Industry Award or Enterprise Bargaining Agreement.
For NDIS claiming purposes, the provider must first determine the day of the week on which the support was provided and then the time of the day during which the support was delivered. Weekday means Monday, Tuesday, Wednesday, Thursday, or Friday.
Types of Support by Time and Day
- Night-time Sleepover Support: This is any support to a participant delivered on a weekday, a Saturday, a Sunday, or a Public Holiday that commences before midnight on a day and finishes after midnight on that day; is for a continuous period of eight (8) hours or more; and the worker is allowed to sleep when they are not providing support.
- Public Holiday Support: This support starts at or after midnight on the night prior to a Public Holiday and ends before or at midnight of that Public Holiday (unless it is a Night-time Sleepover Support).
- Saturday Support: This support starts at or after midnight on the night prior to a Saturday and ends before or at midnight of that Saturday (unless it is a Public Holiday or Night-time Sleepover Support).
- Sunday Support: This support starts at or after midnight on the night prior to a Sunday and ends before or at midnight of that Sunday (unless it is a Public Holiday or Night-time Sleepover Support).
- Weekday Support: Any other support.
For disability support workers:
- Weekday Daytime Support: Any support to a participant that starts at or after 6:00 am and ends before or at 8:00 pm on a single weekday (unless it is a Public Holiday or Night-time Sleepover Support).
- Weekday Evening Support: Any support to a participant that starts at or after 8:00 pm and finishes at or before midnight on a single weekday (unless it is a Public Holiday or Night-time Sleepover Support).
- Weekday Night Support: Any support to a participant that commences at or before midnight on a weekday and finishes after midnight on that weekday, or commences before 6:00 am on a weekday and finishes on that weekday (unless it is a Public Holiday, Saturday, Sunday or Night-time Sleepover Support).
For nurses delivering nursing supports:
- Weekday Daytime Support: Any support to a participant that commences before 12.00 noon on a Weekday and finishes on the same day (unless it is a Public Holiday, Weekday Evening, or Weekday Night Support).
- Weekday Evening Support: Any support to a participant that commences not earlier than 12.00 noon on a Weekday and finishes after 6.00 pm on the same day (unless it is a Public Holiday Support).
- Weekday Night Support: Any support to a participant that commences on or after 6.00 pm on a Weekday and finishes before 7.30 am on the following day (unless it is a Public Holiday Support).
If a support to a participant does not meet one of the above criteria, then it needs to be billed as two or more separate supports. An exception to this general rule occurs when a particular support crosses a shift boundary and the same worker delivers the entire support. In this case, the higher of the relevant price limits applies to the entire support and the provider should make the claim against the relevant support item. Providers are required to discuss this billing arrangement with the participant.
Night-Time Sleepover Supports
This support provides a participant with assistance with, or supervision of, personal tasks of daily life where overnight support is needed, but the caregiver can sleep when not required to provide support. This support applies to any day of the week and on public holidays. This support item includes up to two hours of active supports provided to the participant for the duration of the period. Providers may claim for the third or additional hour at Saturday rates on weekdays, or at applicable rates on other days (Saturday, Sunday, or Public Holidays).
Note: There is no night-time sleepover support item for nurses.
Conclusion
At Trusted Care & Support Services, we understand the importance of adhering to the NDIS claiming rules and creating comprehensive Service Agreements. These practices ensure that our participants receive high-quality care, understand their services, and can trust in the transparency and integrity of our billing practices. By following these guidelines, we continue to provide reliable, effective, and compassionate support to those who need it most.
Understanding the various types of supports and their respective claiming rules can be complex, but it is essential for ensuring compliance and providing the best possible care. Whether it’s a night-time sleepover support, public holiday support, or weekday support, knowing the specifics helps in accurate billing and fosters trust between the provider and the participant.
If you have any further questions about our claiming processes or service agreements, please do not hesitate to contact us. Trusted Care & Support Services is here to help you navigate the complexities of the NDIS and ensure you receive the support you need in the most transparent and effective manner.