NDIS Pricing Pitfalls: Rates, Conflicts, and Billing Traps

Will, EnableUs Community

I was, um, I was talking to a registered provider last week, Winter, and, and they were completely convinced that because their service agreement listed the exact maximum price limit, they were, you know, totally safe. Safe as houses. But the compliance auditor flagged them. Like, actually flagged them for telling the participant that the rate was, quote, set by the NDIA. They had it right there in their standard email template.

Winter, EnableUs Community

Wait, flagged them for that? But, I mean, almost everyone says that, don't they? Like, oh, this is the NDIS mandated rate, we have to charge it. Is that actually against the rules?

Will, EnableUs Community

It is. It is a major violation. The actual Pricing Arrangements and Price Limits document, the PAPL, explicitly says providers should not indicate in any way to participants that the prices they charge are set by the NDIA. Because, see, those limits, they are, they are ceilings. They are caps, not fixed rates. When you tell a participant that the NDIA sets your specific rate, you are misrepresenting the rules. You are essentially taking away their right to negotiate. And for self managed participants, they can negotiate whatever, but even for plan managed and NDIA managed, those price limits are just the absolute maximum you can legally charge, not a mandated flat rate.

Winter, EnableUs Community

Wow, okay, so, so by calling it mandated, you are basically hiding the fact that they could, in theory, negotiate a lower rate with you. That is a massive distinction. I bet a lot of providers are doing that without even realizing the risk. It is just built into their standard sales pitch.

Will, EnableUs Community

Exactly, it is, it is incredibly common. But the NDIA is cracking down on pricing compliance, and if an auditor sees that you are framing these caps as non negotiable government mandates, you are in trouble. You have to be clear that these are maximum limits and that prices are agreed between you and the participant.

Winter, EnableUs Community

Right, okay, that makes sense. And speaking of compliance risks, there is another huge thing in the twenty five to twenty six PAPL update that people are tripping over. It is the whole conflict of interest thing. If an organization is wearing multiple hats, like, if you are doing plan management but you also provide the actual support workers or therapy, you cannot just, um, you cannot just verbally say, oh, by the way, we do both. It is way more formal now.

Will, EnableUs Community

Oh, yes. The, the conflict of interest rules have been completely beefed up. You actually have to formally execute and document a specific Conflict of Interest Declaration Form. It cannot just be a quick chat or a line in a welcome pack anymore. If you are plan managing someone and also delivering their direct supports, that is an inherent conflict. You have to show, with paper, exactly how you are keeping those roles separate and that the participant fully understands they have a choice.

Winter, EnableUs Community

So it is about, um, active, documented transparency. If you do not have that signed declaration on file, and you are auditing, you are basically sitting on a ticking compliance time bomb.

Winter, EnableUs Community

And speaking of time bombs, let us talk about billing. There is this massive transition lag with therapist travel that has been tripping up so many allied health practices since the mid year changes. Will, did you see how many providers missed the change to the therapy travel billing rate?

Will, EnableUs Community

Oh, it is, it is messy. So, basically, from July last year, therapists can only bill their travel time at fifty percent of their standard hourly rate for school and home visits. It used to be one hundred percent. And there are still those rigid caps, like, thirty minutes for metropolitan areas and sixty minutes for regional. But if your billing software is still set up the old way, charging the full hourly rate for travel, you have been, well, systematically overclaiming for months.

Winter, EnableUs Community

Fifty percent. That is a massive cut to travel revenue, and if you have not updated your billing templates or your staff do not know, you are literally overcharging every single time a therapist drives to a client. That is an instant repayment demand if you get audited.

Will, EnableUs Community

An instant repayment, absolutely. And, you know, another place where the line is drawn so, so sharply now is personal trainers. The PAPL has made it crystal clear. Personal trainers are not recognized as therapy providers under NDIS pricing arrangements. Period.

Winter, EnableUs Community

Right. Because, I mean, exercise physiology is claimable as a therapeutic support, but that is delivered by an accredited exercise physiologist. Some providers were, like, substituting a personal trainer because, oh, they do similar fitness work, and then billing it under therapy. But the NDIA says, no, personal training is completely barred from those lines.

Will, EnableUs Community

Yeah, you cannot do it. If you claim personal training under a therapy line, even if the goals are physical wellness, that is a direct compliance breach. You have to make sure the qualification of the person delivering the service perfectly aligns with the support item you are claiming against.

Winter, EnableUs Community

Which brings us to the actual codes themselves. This is my absolute favorite operational tip for providers. You have to know the difference between a legacy support and a deactivated support. Legacy supports are, like, phased out codes. They still show up in the catalogue and you can still claim them for now, but they are a warning sign that the code is dying. Deactivated supports are, well, they are dead. If you try to claim a deactivated code, it will reject instantly, and doing it repeatedly flags your account for an audit.

Will, EnableUs Community

Yes, yes, it does. So, honestly, the best thing you can do is set a calendar reminder for the first business day of every single new financial year. Go through the new Support Catalogue, check every single code your team regularly claims, and make sure none of them have been deactivated or turned into legacy supports. It takes an hour, but it saves you months of rejected claims and audit stress.

Will - BackUp Voice

Such a simple fix. Well, that is a wrap on this quick take. Keep those service agreements compliant, check your travel rates, and we will talk to you next time.

Will, EnableUs Community

See ya.