Health Insurance (1992 Pathology Services Table) Regulations 1991 No. 442
EXPLANATORY STATEMENT STATUTORY RULES 1991 No. 442
Issued by the authority of the Minister for Health, Housing and Community Services Health Insurance Act 1973
Health Insurance (1992 Pathology Services Table) Regulations
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 Health Insurance Act 1973 (the Act) provides that the Governor- General may make Regulations, not inconsistent with the Act, prescribing all matters required or permitted by the Act to be prescribed, or necessary or convenient to be prescribed, for carrying out or giving effect to 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 (1991-1992 Pathology Services Table) Regulations prescribe such a table.
Section 9 of the Act provides, in effect, that medicare benefits shall be calculated by reference to the fees for pathology services set out in the table of pathology services (the table) in Schedule 1A to the Act.
These Regulations introduce patient episode initiation (transaction fee) items, and result from major reforms to the practice of pathology announced in the 1991 Budget. The Pathology Advisory Committee, an industry/government body, has endorsed the reforms.
The Minister for Health, Housing and Community Services agreed to the amendments, the details of which are set out below, which amended the table and its rules of interpretation.
Regulation 3 repealed Statutory Rule 1991 No.353 which consisted of the table including the rules of interpretation which has operated since 1 December 1991.
Regulation 4 introduced the new table and rules of interpretation to operate from 1 February 1992.
Proposed rule of interpretation 1 revises the term "patient episode". Otherwise proposed rules 1 - 10 mirror rules 1 - 4 and rules 6 - 11 of Statutory Rule 1991 No.353
which have operated since 1 December 1991. Of rule 5 in Statutory Rule 1991 No.353 sub-rule 5(1) is included as a definition in new rule 11, and sub-rules 5(2) and (3) are omitted because they describe the circumstances in which the "SP" and "OP" symbols do not apply, and there are no longer "SP" and "OP" rates for pathology services in the table.
In the proposed new rule of interpretation 11 sub-rule 11(1) includes a number of definitions from part IIA of the Act and of the terms "prescribed laboratory", "institution" and "treating practitioner" for the purposes of the 9 items in new Group P10 and 1 item in new Group P11 of the table, which will carry the patient episode initiation fees.
Other fees for items in the proposed table, apart from certain histopathology and cytology items, have been reduced to 70% of the former "SP" rate.
The Regulations will come into effect on 1 February 1992.
Overview
The Health Insurance (1992 Pathology Services Table) Regulations 1991 No. 442, issued under the Health Insurance Act 1973, address the need for updating the pathology services table in light of major reforms to pathology practices announced in the 1991 Budget. The Health Insurance Act 1973 allows the Governor-General to make regulations necessary or convenient for the Act's operation, including prescribing a table of pathology services. These regulations aim to reflect the reforms endorsed by the Pathology Advisory Committee, an industry/government body, and agreed upon by the Minister for Health, Housing and Community Services. The new table, effective from 1 February 1992, introduces patient episode initiation fees and revises definitions, while other fees for pathology services are reduced to 70% of the former "SP" rate, aligning with the policy objective of reforming and updating the pathology services framework.
Scope and Application
The Health Insurance (1992 Pathology Services Table) Regulations 1991 apply to entities and individuals within the health insurance industry in Australia, specifically those involved in the provision of pathology services, and those who are beneficiaries of Medicare. The Regulations are made under the Health Insurance Act 1973, which governs the payment of medical benefits, hospital services, and related matters. The Regulations prescribe a table of pathology services, which determines the fees for which Medicare benefits are calculated. The Regulations extend to the entire Commonwealth of Australia and affect all pathology services provided within its jurisdiction. There are no stated exclusions or exemptions within these Regulations, although certain histopathology and cytology items have been reduced to 70% of the former "SP" rate. The Regulations are amended and extended through subordinate instruments, such as Statutory Rules, which may further define terms or adjust fees as necessary.
Key Provisions
The Health Insurance (1992 Pathology Services Table) Regulations 1991 (No. 442) primarily deal with the replacement and revision of the pathology services table under the Health Insurance Act 1973 (the Act). Section 4A of the Act allows the Governor-General to make regulations that prescribe a table of pathology services, which determines the fees for which Medicare benefits are calculated. These Regulations specifically introduce patient episode initiation items and reflect major reforms to pathology practice announced in the 1991 Budget. Regulation 3 repeals the previous Statutory Rule 1991 No. 353, which was in effect since 1 December 1991, while Regulation 4 introduces the new table and rules of interpretation effective from 1 February 1992.
These Regulations impose specific obligations on parties involved in the provision of pathology services under the Health Insurance Act 1973. They mandate that Medicare benefits be calculated based on the fees set out in the prescribed table, which is now updated to reflect the new patient episode initiation items and reduced fees for most services. The new table and rules of interpretation provide clarity on terms such as "patient episode" and define key terms like "prescribed laboratory", "institution", and "treating practitioner". These definitions and rules are essential for ensuring that the correct fees are applied and that the services are accurately billed and reimbursed under the Act.
The Health Insurance Act 1973 does not explicitly state specific offences, penalties, or civil and criminal consequences for breaches of the Regulations within the Act itself. However, breaches of any regulations made under the Act could potentially lead to enforcement actions by relevant authorities. Non-compliance with the prescribed fees and rules could result in disputes over the correct amount of Medicare benefits payable, which might lead to investigations and corrective actions. The penalties for non-compliance would typically be determined by the specific provisions of other related legislation or administrative actions taken by the Department of Health or other relevant bodies.
Given that the Regulations are closely tied to the Health Insurance Act 1973, any failure to adhere to the prescribed table of fees and rules of interpretation could indirectly result in financial discrepancies and potential legal challenges. Health service providers and patients may face difficulties if the correct fees are not applied, potentially leading to disputes that would need to be resolved through administrative or judicial processes. The exact nature of penalties would depend on the specific circumstances of non-compliance and the applicable laws and regulations.