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[2025] FCA 511
Federal Court of Australia
2025-05-20
Wheelahan J
Original judgment source is linked above.
Note: Entry of orders is dealt with in Rule 39.32 of the Federal Court Rules 2011.
Note: Entry of orders is dealt with in Rule 39.32 of the Federal Court Rules 2011.
(1) The Respondent's usual processing time for claims for payment within 2 to 3 days of their lodgement.
(2) The Respondent has delayed, and intends further to delay, the payment of certain claims made by the Applicant to many weeks (by reason of manually processing each claim).
(3) The scheme of the NDIS Act does not envisage that the process of assessing a claim for payment under s 45 of the NDIS Act should be a matter of great complexity that requires procedures or processes which are inherently time consuming.
(4) The NDIS Act does not provide for any formal hearing or inquiry into such claims, nor does it confer any investigative powers on the Agency in support of the process.
(5) Any manual payment integrity review that is initiated by the Agency in respect of a particular claim should be determined quickly, and in the vicinity of two weeks after the provision of documents in response to a request for information to substantiate the payment.
(6) There do not exist reasonable grounds to withhold payment in the circumstances of this matter.
(7) The Respondent has not given a time by which the Applicant's claims for payment will be accepted or rejected.
(1) Declarations pursuant to s 16(3) of the ADJR Act that there has been unreasonable delay by the Agency in making a decision under s 45 of the NDIS Act in respect of each of the payment claims identified by the Agency in batches that carried a specified "RTP" number. The batches the subject of the proposed declaration totalled approximately 30 in number and comprised thousands of individual claims.
(2) An order under s 16(3) of the ADJR Act that the Agency forthwith make a decision under s 45 of the NDIS Act in respect of each of the payment claims made by the applicant within the identified batches, with an additional requirement that within seven days of the Court's judgment the Agency file an affidavit as to its compliance with the Court's order.
(a) the NDIS Act;
(b) the Public Governance, Performance and Accountability Act 2013 (Cth) (the PGPA Act); and
(c) the ADJR Act.
(a) to manage, and to advise and report on, the financial sustainability of the Scheme, including by identifying and managing risks and issues relevant to the financial sustainability of the Scheme (s 118(1)(b)(ii));
(b) to prevent, detect, investigate and respond to misuse or abuse of, or criminal activity involving, the Scheme (whether systemic or otherwise) where this relates to (relevantly) claims for payment under the Scheme (s 118(1)(ba)(i)); and
(c) to do anything incidental or conducive to the performance of the above functions (s 118(1)(h)).
...
The Agency processes approximately 400,000 claims per day. Many of these claims do not contain sufficient information to identify whether the claim is appropriate to be paid under the Scheme. This can cause delays and additional burdens on participants in responding to requests for information. New section 45A outlines the mechanical requirements for a claim. For a claim to be payable, it must be made by an authorised person, be made in the approved form, and contain all required information. This is in addition to the other substantive requirements in the Act, such as section 45. It will also become a requirement for a claim to be made within two years of the support being provided.
This measure will enable the NDIA CEO to adhere to obligations under the P_ublic Governance, Performance and Accountability Act 2013_ including by enabling claims to be processed quickly while balancing fraud and data quality risks. The NDIA CEO retains some discretion to allow claims which do not meet these requirements where it is appropriate to do so.
...
(a) the board of the Agency, as its accountable authority, must govern in a way that promotes the proper use and management of public resources of the Scheme and its financial sustainability, and must promote the achievement of the purposes of the entity (s 15);
(b) the board of the Agency must establish and maintain appropriate risk and control systems (s 16);
(c) the board of the Agency must also take "all reasonable measures to prevent, detect and respond to fraud and corruption relating to the entity" (s 102, s 10 of the Public Governance, Performance and Accountability Rule 2014 (Cth));
(d) the officials of the Agency, which include its employees, are subject to general duties of reasonable care and diligence in the exercise of powers, the performance of functions, and the discharge of duties (s 25); and
(e) the officials of the Agency, which include its employees, are subject to a duty to act honestly, in good faith, and for a proper purpose in the performance of functions and the discharge of duties (s 26).
The notices from the NDIS Quality and Safeguards Commission
(1) The applicant had submitted claims for services provided to three people while they were incarcerated, which services the applicant did not provide. The letter stated that the claims that were referrable to the three people who were incarcerated totalled $26,062.63, and characterised the claims as fraudulent.
(2) The applicant had submitted claims in relation to supports claimed to have been provided to three people after their dates of death. These claims were said to total $77,554.16, and were also characterised as fraudulent.
(3) An employee of the applicant had uploaded a video to YouTube which disclosed the personal details of 30 NDIS participants contrary to privacy obligations. At the time of the letter, the video had been taken down.
(a) there had been administrative failures and honest mistakes in relation to a small subset of claims which were isolated and not systemic and not of a nature that would compromise the applicant's business;
(b) fraud was a very serious allegation to make, and was not supported by the evidence;
(c) the applicant did in fact provide services to participants while they were incarcerated, and with the full knowledge of the Agency;
(d) in instances where participants had been unexpectedly incarcerated, claims had been made for short notice cancellations in accordance with the NDIS Pricing Arrangements and Price Limits policy, but that some staff had omitted to select the "cancellation" option in the portal when submitting the payment; and
(e) in instances where claims had been made following the death of a participant, it appeared that they may have been made under the NDIS Bereavement Addendum, which authorised weekly payments for a period of up to 4 weeks.
The Agency's decision to conduct a manual review of the applicant's claims
(a) was managed by someone other than the company director, who had previously declared bankruptcy;
(b) enticed potential Specialist Disability Accommodation (SDA) investors with promises of unrealistic investment returns;
(c) traded while insolvent, relying on new investment cash from SDA investors;
(d) utilised funds received from investors for SDA investment purposes by the company for its own operation and private use;
(e) misused NDIS funding by:
(i) only providing one support when a participant was meant to be supported with 2:1 supports, leading to the funding for the relevant plan being exhausted;
(ii) charging for Supported Independent Living (SIL) supports at a 1:3 rate, even though there were 4 participants residing in the SIL;
(iii) overutilizing and prematurely exhausting funding in participants' plans;
(iv) evicting participants from SDAs on the basis the participant did not agree to utilise the applicant for their services;
(v) charging for services which were not provided (multiple complaints); and
(vi) charging for community access when no such services were provided;
(f) continued to charge a support service fee after a participant's death;
(g) treated participants carelessly, thereby putting them at risk; and
(h) hired unqualified staff and underpaid them.
Basis for Qualified Opinion
During our audit, we encountered significant limitations in obtaining sufficient, appropriate audit evidence. Inadequate documentation, incomplete disclosures, unsupported entries, and weak internal controls affected our ability to verify the accuracy and completeness of recorded amounts and disclosures. These conditions, coupled with inconsistent and sometimes unclear records, can create an environment that heightens the risk of errors or intentional misstatements going undetected. Key issues included:...
Qualified Opinion
In our opinion, except for the possible effects of the matters described in the Basis for Qualified Opinion section, the financial statements of Horizon Sol Solutions Australia Pty Ltd as at 30 June 2024, and for the year then ended, may not accurately present the Company's financial position, financial performance, and cash flows in accordance with Australian Accounting Standards and NDIS reporting requirements.
Going Concern:
We draw attention to Note 1 in the financial statements, which describes the significant uncertainty related to the Company's financial position as of 30 June 2024. The Company owed $9,546,902 to the Australian Taxation Office (ATO) and was issued with a bankruptcy notice. However, management successfully negotiated a payment plan approved by the ATO in November 2024, and the default judgment was set aside in October 2024. This indicates an existence of a material uncertainty prior to November 2024 that would have cast significant doubt on the Company's ability to continue as a going concern. Our opinion is not modified in respect of this matter.
RTP2529, RTP2530, RTP2531, RTP2532, RTP2533, RTP2534, RTP2535, RTP2555, RTP2556, RTP2557, RTP2558, RTP2559
(a) the applicant has lodged its claims for payment;
(b) the Agency has sent written requests for information to the applicant requiring it to assemble and produce supporting documentation, generally within 14 days;
(c) the applicant has responded to the requests for information by producing documents which in respect of most of the "RTP" batches of claims have comprised hundreds of individual documents, and in total have comprised thousands of documents;
(d) the documents are reviewed by a case worker assigned to the matter;
(e) upon the case officer reviewing the documents, the case is examined by a supervisor for quality assurance purposes;
(f) a letter is sent to the applicant inviting comment upon any preliminary findings;
(g) any comments from the provider are then considered; and
(h) when the review is finalised, an outcome letter is sent to the claimant which includes notification that any rejected claims may be resubmitted.
(a) the date the claims were submitted;
(b) the date the claims were assigned to a case officer;
(c) the date on which a letter requesting information was sent to the applicant;
(d) the date of any response to the request for information;
(e) the course of the review, including quality assurance by a case supervisor;
(f) the expected timeframe for invitations to the applicant to comment on preliminary findings.
(a) 200 claims to a value of $143,550.73 were made;
(b) 83 claims to a value of $81,587.31 had been decided by the Agency to be payable;
(c) of the 117 claims to a value of $62,963.42 that were undecided -
(i) 66 claims to a value of $33,986.81 were the subject of invitations to comment; and
(ii) 51 claims to a value of $27,976.61 remained subject to ongoing review; and
(iii) more than six weeks had elapsed since the applicant had submitted its response to the Agency's request for information.
(a) there was no real justification to assess all of the applicant's claims as "high risk", and that doing so was predominantly based on false conclusions that services were not provided to incarcerated people;
(b) in any event, there were perfectly adequate alternatives to reviewing manually all payment claims that the Agency could have adopted which would have been more efficient whilst still protecting the financial interests of the Agency; and
(c) in the circumstances, the delay was unreasonable.
(a) the Agency should manually review fewer payment claims;
(b) the Agency should review the claims individually rather than bundling them up in batches;
(c) if the Agency is not satisfied that a claim has been substantiated, it was open to the Agency to refuse the claim rather than going through a process of making preliminary findings and inviting comment; and
(d) the Agency could manually review each claim, but withhold only a portion of the claims and otherwise pay the remainder in the ordinary way within two to three business days.
(a) the subject matter of the power concerns the payment of public moneys;
(b) the statutory purpose may broadly be identified as facilitating the payment of amounts which are properly payable under the Scheme;
(c) the importance of the exercise of the power is informed by a number of competing interests -
(i) the public interest requires that only valid claims are paid and recovery of wrongly paid moneys pursuant to Part 1 of Chapter 7 of the NDIS Act is inherently uncertain and would involve spending yet further moneys and resources;
(ii) the Scheme operates in a context where there are significant concerns about payment integrity, including fraud on the NDIS;
(iii) participants in the Scheme have an interest in ensuring that claims are only made where supports or services have in fact been provided; and
(iv) the applicant has an interest in the prompt payment of valid claims;
(d) the likely prejudicial impact upon the applicant of any delay is essentially commercial and, more particularly, concerned with cash flow considerations while the corresponding prejudice in incorrect payment is, as outlined above, the spending of potentially irrecoverable public moneys; and
(e) the practical limitations which attend s 45 of the NDIS Act by reason of the nature of the decision that was required, and the preparation, investigation and considerations called for are relevant, insofar as the payment review is likely (as in this case) to involve review of many individual transactions and (to the extent that substantiating information is provided) many corresponding documents.
(a) there is a legitimate concern about the accuracy of the applicant's claims for payment;
(b) the applicant had accepted that there had been instances where it has overcharged and the Agency should be refunded, and had accepted that further refunds may be required;
(c) it was reasonable to expect that in reviewing claims in these circumstances, the review will be conducted with a degree of scrutiny;
(d) the resources of the team reviewing payment claims were not unlimited, and staff were working at full capacity;
(e) three active Federal Court proceedings had placed additional demands on the Review Team, affecting their ability to review and process claims;
(f) the nature of the task is to manually review each payment claim, which can involve reviewing information including invoices, service agreements, support notes, pay slips, rosters and timesheets, support worker details and travel logs, and communications with third parties to verify claims;
(g) the review of the applicant's claims for payment the subject of these proceedings required the Agency, amongst other things, to -
(i) issue multiple letters to the applicant seeking information;
(ii) review and cross check voluminous documents and information submitted by the applicant;
(iii) deal with links to information provided by the applicant that cannot be opened and viewed; and
(iv) prepare preliminary findings and letters to the applicant inviting them to comment.
The question is whether there are circumstances which a reasonable man might consider render this delay justified and not capricious. In the first instance it is, on the evidence, a delay for a considered reason and not in consequence of neglect, oversight or perversity. ...
I certify that the preceding ninety-one (91) numbered paragraphs are a true copy of the Reasons for Judgment of the Honourable Justice Wheelahan.
Horizon Solsolutions Australia Pty Ltd
National Disability Insurance Agency [2025] FCA 511
Affinity Care Services Pty Ltd v National Disability Insurance Agency [2024] FCA 1314
AQM18 v Minister for Immigration and Border Protection [2019] FCAFC 27; 268 FCR 424
Australian Epic Health Services Pty Ltd v National Disability Insurance Agency [2025] FCA 449
Australian Securities and Investments Commission v Hellicar [2012] HCA 17; 247 CLR 345
BMF16 v Minister for Immigration and Border Protection [2016] FCA 1530
Bus v Sydney County Council [1989] HCA 29; (1989) 167 CLR 78
Carr v Western Australia [2007] HCA 47; 232 CLR 138
Federal Commissioner of Taxation v Official Receiver [1956] HCA 24; (1956) 95 CLR 300
Health Insurance Commission v Peverill [1994] HCA 8; (1994) 179 CLR 226
Northern Disability Services Pty Ltd v National Disability Insurance Agency [2024] FCA 892
Patrick v Australian Information Commissioner [2024] FCAFC 93; 304 FCR 1
Teubner v Humble [1963] HCA 11; (1963) 108 CLR 491
Thornton v Repatriation Commission [1981] FCA 76; (1981) 52 FLR 285
(1989) 167 CLR 78
(1992) 39 FCR 458
(1956) 95 CLR 300
(1994) 179 CLR 226
(1963) 108 CLR 491
(1981) 52 FLR 285