Health Insurance (1992 Pathology Services Table) Regulations (Amendment)
1992 No. 273
EXPLANATORY STATEMENT
STATUTORY RULES 1992 No. 273
Issued by the authority of the Minister for Health, Housing and Community Services
Health Insurance Act 1973
Health Insurance (1992 Pathology Services Table) Regulations (Amendment)
The Health Insurance Act 1973 (the Act) provides for payments by way of medical benefits, payments for hospital services and payments for matters concerning related committees and tribunals.
Section 133 of the Act provides that the Governor-General may make regulations for the purposes of the Act.
Section 4A of the Act provides 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 prescribed table has effect as if it were set out in Schedule 1A in place of the table in that Schedule. The Health Insurance (1992 Pathology Services Table) Regulations (Amendment) amend such a table.
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 (the table)) in Schedule 1A to the Act.
The Regulations refine the descriptions of a number of items in the table, revise the descriptions and the fees of items in the Immunology Group of items in the table, and introduce 2 new rules to the Rules of Interpretation of the table. One rule permits exemptions from an existing rule which allows for 2 or more requests for pathology services to be taken to have been rendered following a single request in certain circumstances, and the other rule provides for a specimen referred fee to be charged in specified circumstances for certain pathology services in place of a patient episode initiation fee, where a laboratory performs pathology services referred on by another laboratory.
Subregulation 3.4 inserts new rule 3A which provides exemptions to rule 3 (the rule which allows 2 or more requests for 2 or more pathology services to be taken to have been rendered following a single request, when the services are listed in the same item and the patient's need for the services was determined on the same day) increasing the number of services to be taken as being rendered in response to a separate request which may be provided for seriously ill in-hospital patients in a 24 hour period, and permitting up to 6 essential tests to be done in a 6 months period to monitor the health of patients with certain strictly defined conditions.
Subregulation 3.5 inserts new rule 5A which defines designated pathology service' by reference to 3 new items proposed for the table, and provides for the payment of a specimen referred fee for a designated pathology service, under item 73921 rather than a patient episode initiation feel, to a laboratory performing tests referred on from another laboratory which has already completed some services listed on the original request.
Subregulations 3.7 - 3.15 contain 17 items, recommended by the Pathology Services Table Committee, which for the most part are in substitution for existing items but with new descriptions. On balance these changes have no financial implications.
Subregulation 3.16 incorporates new item descriptors and fees (including an average 4.85% increase in fees) for the Immunology Group of items in the table, recommended by the Pathology Services Table Committee as a result of a review of that group of items commenced in February 1990 and agreed to by the Minister for Health, Housing and Community Services.
The Regulations are to commence on 1 September 1992.
Overview
The Health Insurance (1992 Pathology Services Table) Regulations (Amendment) 1992 No. 273 were introduced to refine the descriptions of pathology services and adjust the fees for certain services under the Health Insurance Act 1973. This legislation, issued by the authority of the Minister for Health, Housing and Community Services, aims to update the Pathology Services Table to ensure it accurately reflects current medical practices and requirements. The amendment introduces two new rules to the Rules of Interpretation, allowing for additional pathology services to be provided to seriously ill in-hospital patients and permitting the charging of a specimen referred fee for certain pathology services performed by laboratories. Additionally, it incorporates new item descriptors and fees for the Immunology Group of items, reflecting a review and agreement by the Minister for Health, Housing and Community Services. The overall objective is to align the pathology services table with contemporary medical needs and practices, ensuring appropriate reimbursement for services provided under the Act.
Scope and Application
The Health Insurance (1992 Pathology Services Table) Regulations (Amendment) 1992 No. 273 amends the pathology services table under the Health Insurance Act 1973, which applies to the provision of medical benefits and payments for hospital services in Australia. These regulations refine and update the descriptions of various pathology services, adjust the fees associated with these services, and introduce new rules governing the interpretation and application of the table. The amendments apply to all entities and individuals engaged in the provision of pathology services under the Act, including laboratories, healthcare providers, and medical practitioners, and are intended to ensure that medicare benefits are calculated accurately and fairly. The amendments are national in scope, applying across all states and territories of Australia, and are set to commence on 1 September 1992. The regulations do not specify any exclusions or exemptions, meaning they apply to all pathology services covered under the Act unless otherwise stated in subordinate instruments.
Key Provisions
The Health Insurance (1992 Pathology Services Table) Regulations (Amendment) 1992 No. 273 amends the Health Insurance (1992 Pathology Services Table) Regulations under Section 133 of the Health Insurance Act 1973. Section 4A of the Act allows for the creation of a table of pathology services, and Section 9 of the Act specifies that Medicare benefits for medical services, including pathology services, are to be calculated based on the fees listed in the pathology services table in Schedule 1A. The Amendment Regulations introduce changes to the pathology services table, including refined descriptions of certain items, revised descriptions and fees for items in the Immunology Group, and two new rules for the interpretation of the table. The first new rule, inserted by subregulation 3.4, is rule 3A, which allows for exemptions from rule 3 that previously permitted multiple requests for pathology services to be considered as a single request if certain conditions were met. The new rule 3A increases the number of services that can be considered separate requests for seriously ill in-hospital patients in a 24-hour period, and permits up to six essential tests in a six-month period to monitor the health of patients with specific conditions. The second new rule, inserted by subregulation 3.5, is rule 5A, which defines a 'designated pathology service' and provides for the payment of a specimen referred fee for such services, under item 73921, rather than a patient episode initiation fee, to laboratories performing tests referred from another laboratory that has already completed some services listed on the original request.
The Amendment Regulations impose specific obligations on the parties governed by the Act. These include the obligation to adhere to the descriptions, fees, and rules outlined in the amended pathology services table. The rules regarding the interpretation of the table, including the exemptions for multiple requests and the specimen referred fee for designated pathology services, must be strictly followed by healthcare providers and laboratories. The obligation to accurately code and bill for pathology services according to the updated table is essential to ensure correct Medicare benefit calculations and compliance with the Act.
Failure to comply with the requirements of the Health Insurance (1992 Pathology Services Table) Regulations (Amendment) may result in civil and criminal consequences. While the specific penalties for breaches of the regulations are not detailed in the explanatory statement, breaches of the Health Insurance Act 1973 can lead to substantial penalties. For instance, Section 142 of the Act provides that a person who contravenes any provision of the Act or regulations may be liable for a civil penalty of up to $22,200 for each offence. Additionally, criminal penalties may apply for more serious breaches, with penalties potentially including fines of up to $111,000 for individuals and $555,000 for bodies corporate, as well as imprisonment. The exact penalties for specific breaches would be determined by the courts based on the nature and severity of the offence.