NDIA Accountability Project

Registration and audit requirements for psychologists under the NDIS

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Australian Association of Psychologists incorporated (AAPi)

NDIS Consultation Questions: New inquiry into current scheme implementation and forecasting for the NDIS

Introduction

The Australian Association of Psychologists incorporated (AAPi) thanks the National Disability Insurance Agency for the opportunity to provide information and recommendations on the current scheme implementation and forecasting for the NDIS.

AAPi represents psychologists traversing a wide range of areas of practice around the country, including working within the National Disability Insurance Scheme.

Using these insights, we would urge the NDIA to strongly consider our recommendations.

Sincerely,

Tegan Carrison Executive Director Australian Association of Psychologists Inc

Phone 0488770044 Email admin@aapi.org.au Website www.aapi.org.au Postal Address PO Box 107 North Melbourne, Vic 3051

Terms of Reference

The Australian Association of Psychologists Inc. has the following feedback about the current scheme implementation and forecasting for the NDIS:

a. The impact of boundaries of NDIS and non-NDIS service provision on the demand
   for NDIS funding, including:

i. the availability of support outside the NDIS for people with disability

                  (e.g., community-based or 'Tier 2' supports)

The introduction of the NDIS has meant that many previously available disability services and supports are no longer available to those who do not have NDIS funding. The vast majority of community programs and supports now exclusively serve individuals with NDIS funding. For those whose disability is not funded by the NDIS or their disability does not reach the threshold of access to the NDIS, they must access privately-funded support or wait for publicly-funded services to become available. There are many disabling conditions that do not meet criteria for the NDIS and a scarcity of available public support and resources. For example, AAPi members have reported that Autism group support is unable to be accessed without funded support from the NDIS. Community supports also require either personal funding or NDIS funding (disability specific art groups, day programs etc).

ii. the future of the Information, Linkages and Capacity Building grants

           program

There seems to be very little uniformity regarding what community-based disability services are available. Consumers cannot readily identify and utilise the supports that are available to them. There needs to be consistently funded mainstream services nationally to support disabled consumers who do not have access to the NDIS rather than ad hoc funding.

b. The interfaces of NDIS service provision with other non-NDIS services provided by
  the States, Territories and the Commonwealth, particularly aged care, health,
   education and justice services

There have been considerable issues with funding allocations for psychology providers under the NDIS with participants being told much more often that they need to access Mental Health Treatment Plans and access 20 “free psychology sessions” before they can use their NDIS provided funding to access psychologists. Sessions under a Mental Health Treatment Plan are not ‘free’. The Medicare system provides a rebate to the patient. Unfortunately, the rebate of $88.25 (1/7/21) does not cover the cost of service – consider for example the NDIS Schedule Rate of $214.41. This means that in most cases the person will have a $128.06 out of pocket expense per session. Medicare specifies that “gaps between rebate and the fee charged by the practitioner are not to be paid by insurance.” Many NDIS participants are on pensions or limited income due to disability and cannot afford to pay out of pocket costs for psychologists. Therefore, many participants will be denied access to psychologists due to the cost.

Mental Health Treatment Plans are for the treatment of specific psychological issues. Medicare specifically excludes diagnoses not related to one of the ICD 10 codes. Treatment for ‘Disability’ only without comorbid\psychopathology is specifically precluded. The Department of Health has directed that Mental Health Care Plans are for treating Mental Health Symptoms. NDIS therapy funding is to treat mental health symptoms that are part of the participants everyday life and result from the participant’s disability.

Treatment under Medicare

Treatment under Medicare is limited to 10 rebates per calendar year – this is inadequate for standard treatment, particularly with complex issues including disability. The client would be required to pay the full session fee and that is likely to impact uptake of treatment.

Although clients can currently access up to 20 rebated sessions, sessions 11-20 cannot be provided in a home visiting capacity, there is currently no item number for this. Clients will have to use telehealth services or attend the clinic which removes choice and control over how they access services.

There are additional restrictions on the type of therapies allowed through Medicare. Medicare restrictions on permitted therapies make the Medicare funding option inappropriate for some disabilities and the treatment goal of functional improvement. Assessment is specifically not permitted under a Mental Health Care Plan.

When psychological treatment or therapy is required to improve functional capacity for someone with a disability, it is therefore reasonable and necessary for this to be funded under their NDIS plan. Participants have a right to use their NDIS therapy funding to seek support from psychologists. Declining participant’s fully funded access to psychologists places participant’s mental health at-risk and violates a number of principles outlined under the current NDS Act, namely choice and control. If providers comply with directions to provide services under Medicare when participants do not meet the Medicare service eligibility requirements, the providers are at risk of being prosecuted for Medicare fraud. With the onus of responsibility (financial, legal, and ethical) on the Medicare provider, seeing an NDIS participant using Medicare funding is simply too risky.

c. The reasons for variations in plan funding between NDIS participants with similar needs, including:
              i.  the drivers of inequity between NDIS participants living in different parts of Australia

Some of the restrictions on the evidence required for NDIS funding is making the application and review process more difficult than it needs to be. Accessing the right provider, to provide the right support and evidence is extremely difficult especially when providers are limited in many regions in Australia. With long wait lists, even in urban areas, many miss out of services in their first plan due to these barriers. Upon review, this may appear that the participant does not need that level of funding in order to improve their functional capacity, when it is simply an indication that adequate services were not accessible to the participant. Telehealth options and internet coverage in rural, regional, and remote areas of Australia mean that not all providers are not able to be accessed by telehealth and extremely lengthy wait times are seen by participants for face-to-face services in these areas. We need to improve the workforce capacity to provide services in these regions by offering incentives, business support and utilising workforce retention strategies to retain the workforce that is available.

ii. whether inconsistent decision-making by the NDIA is leading to inequitable variations in plan funding

Decisions about funding levels really depends on the Local Area Coordinator (LAC) who has completed the interview and the planner that is allocated. It is very common to see significant funding variations between almost identical participants (same disability, same functional deficits, same living situation). For example, a member provided an example of two very similar child clients where one receives $28k per year while the other receives $9k per year.

Oftentimes, allied health and specialist reports do not appear to be consulted at all in the decision making. Some funding comes with decisions that go directly against the Act which leads to lengthy reviews or appeals to the Administrative Appeals Tribunal (AAT) and requiring therapist support to assist the participant to self-advocate. It is very difficult when the person who completes the interview is not the one who plans the funding or has any real concept of the individual’s disability due to not meeting the participant face to face or speaking with them at all. It brings decisions down to rudimentary numbers and reduces the context and individual factors present.

Similarly, one participant may receive funding for fortnightly psychology sessions while another very similar participant is told that psychology is funded via a MHCP, and no psychology therapy funding is provided.

Inconsistent decision making has resulted in clients missing out on what they need. Clients who cannot ask for their needs to be met due to their disability often miss out on services altogether or receive inadequate funding. It is common for accessibility needs to not be funded even when someone has access to the NDIS, but many cannot access support at all.

ii. assumptions, measures, and methodologies used to forecast and make

projections about the scheme, participants, and long-term financial modelling;

We will provide further comments on this section for the final report.

 f. The measures intended to ensure the financial sustainability of the NDIS (e.g.,

governance, oversight and administrative measures), including: ii. the arrangements for providing actuarial and prudential advice about the scheme, and

The billing practices of allied health practitioners has been discussed and referenced with the assumption that some providers are behaving unethically or irresponsibly due to the majority of billing being in the upper limit of the NDIS price guide. We would like to draw attention for a number of factors that are influencing these billing practices; - client complexity – clients referred through NDIS require significantly more inter-professional and multi-disciplinary liaison, carer contact, resource preparation, risk management, therapy accommodations/modifications, assessment, report preparation, as well as assistance with advocacy. - business costs including audit costs – for a smaller size organisation, audit costs can be between $1000 to $15000 per year with additional costs incurred in the time and energy producing the required policies and procedures. - COVID-19 pandemic disruptions – the extra requirements that have needed to be put in place due to the COVID-19 pandemic include the purchase/subscription to telehealth platforms, increased cost of administration to collect fees, frequent client cancellations, client withdrawal from treatment due to not wishing to engage in telehealth services or wear masks during session, cost of mask purchase and high consumption of cleaning/sanitation supplies, restrictions on how many people are able to be in a workplace at one time. - unpaid portion of NDIS work – administration is more extensive for billing and invoicing (claiming payment through either the portal, the third-party payer, or chasing payment from a self-managed client who often cannot pay at the time of service). There is increased communication and collaboration with stakeholders involved in client care, which are more common and frequent than with non-NDIS clients. Due to increased complexity, session preparation, resource preparation and therapy research there is more time consumed outside of billable work. Plan review reports are extensive and more complex than other funding body reporting requirements. - non-payment-we have heard from many members that there are issues receiving payment for services, particularly when not notified of plan changes, other providers sectioning funding away from psychology services or funding running out prior to review. A significant amount of administration

  • time is taken following up unpaid fees and there are oftentimes lengthy

  • delays in payment. Reserves need to be available to meet payroll while

  • awaiting balances to be paid and to account for bad debts that will never

  • arrive. Some practitioners have had to take short term loans to meet payroll

  • because of these lengthy delays. In standard business practices, terms of

  • service would be payment upon provision of service or within 28 days. In

  • NDIS delivered services this can turn into months. Better processes need to

  • be put into place to ensure providers are paid quickly for services provided.

  • the recommended fee for hourly psychology services. The hourly rate

  • recommended by AAPi for psychology services is $265. This is higher than the

  • NDS rate claimed by psychologists, indicating that psychology is still funded

  • at levels that are too low, given the education, training, and business costs

  • associated with registration and practice as a psychologist. Members, for the

  • large part have been resistant to charge our recommended fee due to the

  • ability of the public and private sectors to pay the recommended fee. We

  • would encourage the NDIS to view psychologists claiming at the upper end of

  • the NDIS maximum fee as appropriate to ensure the viability of high-quality

  • service provision.

  • high requirements for professional development and training – the cost of

  • training and the professional development required for psychologists to work

  • in the disability field are high. To maintain registration, psychologists need to

  • undertake at least 30 hours of professional development each year. For those

  • working in areas that are highly specialised, such as the disability field, more

  • training is required in order to practice within one’s area of competence

  • which is a requirement for psychologists. Psychologists are highly skilled and

  • have a high level of education and development, requiring large amounts of

  • professional development on an ongoing basis.

g. The ongoing measures to reform the scheme including: i. the new early childhood approach, including whether or how early intervention and other supports intended to improve a participant’s functional capacity could reduce their need for NDIS funding

AAPi supports the new early childhood approach. Early intervention has a strong evidence base and we support further investment in both early childhood and early intervention.

ii. planning policy for personalised budgets and plan flexibility

Personalised budget and plan flexibility is incredibly important. The needs of each individual are unique and AAPi support further work to ensure that individual budgets and plans are flexible and appropriate. h. Any other related matters.

  • We like to raise our concerns regarding current registration and audit requirements.

  • Practitioners who are required to been registered with AHPRA, such as psychology,

  • should not be required to go through another process to be registered providers of NDIS

  • services. Psychology is already a highly regulated allied health profession and the

  • requirements for NDIS registration is unnecessary and burdensome.