Health Insurance (1996-97 Diagnostic Imaging Services Table) Regulations
(Amendment) 1997 No. 12
EXPLANATORY STATEMENT
STATUTORY RULES 1997 No. 12
Issued by the authority of the Minister for Health and Family Services
Health Insurance Act 1973
Health Insurance (1996-97 Diagnostic Imaging Services Table) Regulations (Amendment)
The Health Insurance Act 1973 ('the Act') provides, in part, for the payment of Medicare benefits for professional services rendered by medical practitioners.
Section 133 of the Act provides that the Governor-General may make regulations for the purposes of the Act.
Section 4AA of the Act provides that regulations may prescribe a table of diagnostic imaging services ("the table") and the Health Insurance (1996-97 Diagnostic Imaging Services Table) Regulations prescribe such a table.
Section 9 of the Act provides that Medicare benefits shall be calculated by reference to the fees for medical services set out in the table ("Schedule fees"). Section 10 of the Act provides that a Medicare benefit is payable at the rate of 75% of the Schedule fee for a service that is rendered in a hospital or a day hospital facility, or at the rate of 85% of the fee in other cases, that is, nonhospital services. Services may be patient billed, or the Medicare benefit may be assigned by the patient to the practitioner under section 20A of the Act, The latter is sometimes referred to as "bulk billing" or "direct billing". If this applies, the practitioner must accept the Medicare benefit in full settlement for the services rendered.
Section 10 also provides that where the rate of 85% applies for a service and the Schedule fee exceeds the amount of benefit by more than the greatest permissible gap, the benefit is taken to be the Schedule fee less the greatest permissible gap.
The greatest permissible gap was changed from $26.80 to $50.00 from 17 December 1996 following the commencement of Item 3 in Schedule 2 of the Health Insurance Amendment Act (No. 2) 1996. This change was part of the 1996 Budget initiatives. Section 10A provides for the greatest permissible gap to be indexed and the figure of 526.80 had been indexed to 530.20 from 1 November 1996,
The effect of the amendment to the greatest permissible gap is to decrease the Medicare benefits Payable for both assigned and patient billed non-hospital services where the Schedule fee for those services exceeds 5201.33.
The purpose of the Regulations is to increase Schedule fees, for items where the Schedule fee exceeds 5201.33, by an amount calculated to provide increased Medicare benefits approximately equal to the decrease in Medicare benefits for assigned non-hospital services. The increased Schedule fee for each item in the Regulations was calculated having regard to the utilisation of services, fees and benefits billed under both assigned and patient billed services, rendered as hospital or non-hospital services from an analysis of statistical data for 1995/96.
The Regulations provide for increases to the fee for items in the diagnostic imaging services table where the fee exceeds $201.33.
The practical outcome of the Regulations is to offset the decrease in Medicare payments for bulk billed non-hospital services.
The Regulations also amend two fluoroscopy items in the table to provide that benefits are payable only where the services are not rendered in association with another radiographic examination.
The Regulations come into effect from 19 February 1997.
Overview
The Health Insurance (1996-97 Diagnostic Imaging Services Table) Regulations (Amendment) 1997 No. 12 were enacted to address the gap in Medicare benefits for diagnostic imaging services as a result of changes in the greatest permissible gap, which was adjusted from $26.80 to $50.00 under the Health Insurance Amendment Act (No. 2) 1996. The Regulations were made under the authority of the Minister for Health and Family Services and pursuant to section 133 of the Health Insurance Act 1973, which allows for the making of regulations for the purposes of the Act. The primary policy objective of these Regulations is to adjust the Schedule fees for certain diagnostic imaging services, ensuring that the decrease in Medicare benefits payable for assigned non-hospital services is offset by an increase in the Schedule fees. This adjustment is aimed at maintaining the integrity of Medicare benefits despite the changes in the permissible gap, thereby ensuring that medical practitioners are adequately compensated for their services.
Scope and Application
The Health Insurance (1996-97 Diagnostic Imaging Services Table) Regulations (Amendment) 1997 No. 12 applies to medical practitioners and patients who are beneficiaries of Medicare under the Health Insurance Act 1973. The Act facilitates the payment of Medicare benefits for professional services rendered by medical practitioners, including diagnostic imaging services. The Regulations amend the diagnostic imaging services table to adjust the fees for specific services, particularly where these fees exceed $201.33, in response to a change in the greatest permissible gap. This adjustment is designed to increase the Medicare benefits payable for services rendered outside of hospital settings, thereby offsetting the decrease in benefits for bulk-billed non-hospital services. The Regulations apply nationally across Australia, as they are made under the Commonwealth Act. The scope of the Regulations does not explicitly exclude any specific persons, entities, or industries, but they focus on those involved in the provision and billing of diagnostic imaging services within the Medicare framework. The Regulations also include specific amendments to two fluoroscopy items to ensure benefits are only payable when the services are not rendered in association with another radiographic examination. The Regulations came into effect from 19 February 1997.
Key Provisions
The Health Insurance (1996-97 Diagnostic Imaging Services Table) Regulations (Amendment) 1997 No. 12 primarily focus on adjusting the fees for diagnostic imaging services under the Health Insurance Act 1973. These amendments aim to compensate for the decrease in Medicare benefits for assigned non-hospital services due to the increase in the greatest permissible gap, which was adjusted from $26.80 to $50.00 effective from 17 December 1996. Section 9 of the Act requires Medicare benefits to be calculated by reference to the fees for medical services set out in the table. The regulations provide for increases in the Schedule fees for items in the diagnostic imaging services table where the fee exceeds $201.33, calculated based on the utilisation of services, fees, and benefits billed under both assigned and patient-billed services for 1995/96.
The amendments impose obligations on medical practitioners, patients, and the Department of Health to comply with the updated fees outlined in the Regulations. Medical practitioners must adjust their billing practices to reflect the new Schedule fees for relevant diagnostic imaging services. Patients may continue to have their services billed directly to Medicare or be patient-billed, depending on their preference and the practitioner's acceptance of bulk billing. The Department of Health is responsible for enforcing the updated fees and ensuring that the correct Medicare benefits are paid according to the amended Schedule fees.
Breaches of the provisions outlined in the Regulations may lead to civil or administrative consequences. Medical practitioners who fail to comply with the updated fees may face penalties for non-compliance, including fines or other sanctions. Patients who knowingly or negligently misrepresent their billing preferences may also face penalties. The Act and Regulations do not specify maximum penalties in the explanatory statement; however, penalties for breaches of the Health Insurance Act 1973 can vary, with potential fines and other administrative actions depending on the severity and nature of the breach. It is crucial for all parties involved to adhere to the amended Schedule fees to avoid any legal or financial repercussions.