Health Insurance (1992-1993 Pathology Services Table) Regulations (Amendment) 1993 No. 125
EXPLANATORY STATEMENT STATUTORY RULES 1993 No. 125
Issued by the authority of the Minister for Health Health Insurance Act 1973
Health Insurance (1992-1993 Pathology Services Table) Regulations (Amendment)
Section 133 of the Health Insurance Act 1973 (the Act) provides that the GovernorGeneral may make regulations for the purposes of the Act.
Section 9 of the Act provides, in effect, that Medicare benefits shall be calculated by reference to the fees for medical services (including pathology services) set out in the table (which includes the pathology services table) in Schedule 1A to the Act.
Section 4A of the Act provides, among other things, that the regulations may prescribe a table of pathology services in accordance with the form of table set out in Schedule 1A and that, upon commencement of a regulation prescribing a table of pathology services, the table so prescribed has effect as if it were set out in Schedule 1A in place of the table in that Schedule. The Health Insurance (1992-1993 Pathology Services Table) Regulations (Amendment) amend such a table.
The Regulation amends the Pathology Services Table which sets down the pathology tests eligible for payment of Medicare benefits and the amount of the rebates.
Amendments include the creation of eleven new items, deletion of five and changes to the wording of five. Fees have been decreased for two items and conditions surrounding the payment of benefits for some items have been changed. The overall effect is expected to be a slight increase in expenditure in Medicare benefits for pathology services. Specialist advice to the minister has been that these changes are justified and will result in an improvement in pathology practice.
Subregulations 3.1, 3.2, 3.7, and 3.8 are editorial amendments designed to improve the presentation of the Rules of Interpretation for the table or to clarify the meaning of the Rules.
Subregulation 3.3 inserts new subrule 2(3) which ensures that only the appropriate item can be claimed for a particular test or group of tests.
There are three proposed amendments to Rule 3A.
Subregulation 3.4 amends paragraph 3A(1)(a) reflecting a change in the description of an item in the pathology schedule.
Subregulation 3.5 removes an unintentional restriction in subrule 3A(2) on the number of tests, in a strictly defined category, which attract benefits within six months, provided that no more than six tests are performed per request form, and that the request is no more than six months old.
Subregulation 3.6 inserts new subrule 3A(2A) to ensure that if a treating practitioner requests that faecal specimens be collected on three different days so as to obtain a valid estimation, three patient episode initiation fees will be paid.
Subregulation 3.9 inserts new subrules 11(6) and 11(7). New subrule 11(6) provides for two patient episode fees to be paid when certain combinations of tests are ordered provided that they are performed by approved pathology practitioners in two separate approved pathology authorities. The combinations include: cytology and histology tests; cytology and other non-cytological tests; and histology and non-histological tests. Subrule 11(7) ensures that if multiple pathology specimens are collected from a patient on one day for one approved pathology authority, only one patient episode fee will be payable.
Subregulations 3.10 and 3.12 omit cholesterol and triglycerides from item 66201 and create new items to ensure that the ordering of lipid tests can be monitored.
Subregulation 3.11 omits item 66233, and subregulation 3.12 substitutes item 66343 which restricts the number-of drug assays which can be performed on patients participating in a drug abuse program from a possible 52 tests in a year to "21 assays in any 12 month period".
Subregulations 3.13 and 3.14 omit item 69225 and substitute two new items to cover new cost effective tests for Chlamydia and herpes simplex virus. Subregulation 3.14 also inserts a new item in the table for the detection of antibodies to hepatitis C to facilitate the monitoring of orders for this test.
Subregulation 3.15 omits three cytogenetic items and substitutes for them two new items which more correctly describe current practices in cytogenetics.
Subregulations 3.16 and 3.17 amend items in Group P9 of the table (Simple Basic Pathology Tests) to accommodate changes in the current provision of simple basic pathology tests by general practitioners. Also the fees for two items have been reduced to bring them in line with fees in other parts of the Pathology Services Table.
These Regulations would commence from 1 July 1993.
Overview
The Health Insurance (1992-1993 Pathology Services Table) Regulations (Amendment) 1993 No. 125 were enacted under the authority of the Minister for Health to amend the Health Insurance Act 1973. The primary objective of these amendments was to update the Pathology Services Table, which determines the pathology tests eligible for payment of Medicare benefits and the corresponding rebate amounts. This regulation was introduced to address gaps and updates required in the existing pathology services table to ensure it reflects current pathology practices and technological advancements. The amendments include the creation of eleven new items, the deletion of five, and modifications to the wording of five items, all aimed at improving the accuracy and relevance of the table. Additionally, fees for two items were decreased, and conditions for the payment of benefits for some items were altered. The overall effect of these amendments is expected to slightly increase expenditure on Medicare benefits for pathology services.
The regulation was enacted by the Parliament of Australia and includes editorial and structural amendments to the Rules of Interpretation for the table, ensuring clarity and precision in the application of the table. These amendments reflect specialist advice indicating that the changes will improve pathology practice and are justified. The Regulations are set to commence from 1 July 1993, ensuring that the updated table is in effect for the financial year.
Scope and Application
The Health Insurance (1992-1993 Pathology Services Table) Regulations (Amendment) 1993 No. 125 apply to all entities and individuals involved in the provision of pathology services under the Health Insurance Act 1973, particularly those eligible for Medicare benefits. This regulation specifically affects medical practitioners, pathology providers, and patients who avail themselves of pathology services in Australia. It pertains to the fees for pathology services set out in the Pathology Services Table, ensuring that the rates and conditions for pathology tests are updated to reflect current medical practices and to maintain the integrity of Medicare. The amendment regulates the conduct of pathology service providers by specifying the tests eligible for Medicare rebates and the corresponding fees, which must be adhered to for the services to be eligible for reimbursement. The regulation operates on a national level, applying across all states and territories of Australia as it is a Commonwealth regulation under the Health Insurance Act 1973. The regulation provides for amendments to the Pathology Services Table, including the addition of new items, deletion of obsolete ones, and modifications to existing entries, thereby ensuring that the table remains relevant and comprehensive. The changes are designed to improve pathology practices and ensure that the benefits paid under Medicare are aligned with current medical standards and practices.
Key Provisions
The Health Insurance (1992-1993 Pathology Services Table) Regulations (Amendment) 1993 No. 125 (the Regulations) are designed to amend the Pathology Services Table under the Health Insurance Act 1973 (the Act). These amendments, detailed in section 4A of the Act, are intended to update the fees and services eligible for Medicare benefits, reflecting changes in pathology practices and ensuring the table accurately represents current medical practices. The amendments include the creation of new pathology service items, deletion of outdated items, and modifications to existing items to better align with current medical standards. For example, new items have been introduced for advanced tests such as the detection of antibodies to hepatitis C, while some older or less relevant tests have been removed to streamline the table. Additionally, the fees for certain services have been adjusted to ensure they remain competitive and reflective of the current market.
The Regulations impose specific obligations on medical practitioners, pathology service providers, and the Department of Health. Medical practitioners must ensure they are aware of the updated table and only claim benefits for services that are listed and eligible under the amended table. Pathology service providers are required to adhere to the new fees and conditions set out in the table when providing services and claiming Medicare benefits. The Department of Health is responsible for maintaining and updating the Pathology Services Table as necessary, ensuring it reflects the most current medical practices and standards. These obligations are critical to maintaining the integrity and efficiency of the Medicare system.
Failure to comply with the Regulations can result in civil and criminal penalties. Practitioners who knowingly or negligently claim benefits for non-eligible services may face financial penalties or be required to repay any benefits improperly claimed. Under the Act, such breaches may also result in criminal charges, particularly if the non-compliance is found to be wilful or negligent. The maximum penalties for such offences can include substantial fines and, in severe cases, imprisonment, reflecting the serious nature of such breaches. Ensuring compliance with the Regulations is therefore crucial for all parties involved to avoid these significant consequences.