Health Insurance (Pathologist-determinable Services) Amendment Determination 2012

Overview

The Health Insurance (Pathologist-Determinable Services) Amendment Determination 2012 was enacted to address issues within the Health Insurance Act 1973, specifically focusing on the determination of pathology services that can be deemed pathologist-determinable without necessitating a request from a treating practitioner. This was enacted to streamline the process for the payment of Medicare benefits for certain pathology services, ensuring that they are accessible under specific circumstances, such as when an Approved Pathology Practitioner (APP) performs services for their own patients or when further tests are required based on earlier results. The amendments were introduced following consultation with the Royal College of Pathologists of Australasia (RCPA), as mandated by the Act. The policy objective is to facilitate the appropriate use of pathology services and ensure that patients receive necessary diagnostic tests without unnecessary delays. The determination also aims to correct errors in item numbers and include additional services that were previously omitted or incorrectly listed. The determination was issued by the Australian Government under the authority granted by the Legislative Instruments Act 2003, and it came into effect on 1 January 2013. It amends the Health Insurance (Pathologist-Determinable Services) Determination 2006, updating the list of services to include new items and correcting previous errors, thereby enhancing the accuracy and effectiveness of the Medicare benefits system in relation to pathology services.

Scope and Application

The Health Insurance (Pathologist-determinable Services) Amendment Determination 2012 applies to pathology services within the scope of the Health Insurance Act 1973. Specifically, it concerns the determination of certain pathology services as pathologist-determinable services, which allows for the payment of Medicare benefits without the need for a request from a treating practitioner. This applies to services performed by Approved Pathology Practitioners (APP) for their own patients or when deemed necessary by the APP based on previous test results. The amendment ensures that services such as genetic tests for specific conditions, like HER2 gene amplification in breast cancer patients, and tissue pathology items, among others, are correctly identified as pathologist-determinable or originally requested services. The amendment also corrects errors in item numbers to align with current listings. This Determination extends to the Commonwealth jurisdiction and is applicable nationally, as it amends the Health Insurance (Pathologist-determinable Services) Determination 2006. The amendments, as outlined in the attached Schedule, commence on 1 January 2013 and include specific changes to item listings and corrections to ensure accurate identification and billing of pathology services under the Act.

Key Provisions

The Health Insurance (Pathologist-determinable Services) Amendment Determination 2012 amends the Health Insurance (Pathologist-determinable Services) Determination 2006 (No. 3), primarily through the adjustments and additions to the list of pathology services that can be classified as pathologist-determinable services (section 3). Section 4BA of the Health Insurance Act 1973 allows the Minister to determine, following consultation with the Royal College of Pathologists of Australasia (RCPA), which pathology services should be classified as pathologist-determinable services. The amendment determination specifically identifies additional services that can be performed without the necessity of a request from a treating practitioner, provided the pathology service is deemed necessary by an Approved Pathology Practitioner (APP) (subsection 4BA(1)). The changes include the addition of services such as in-situ hybridization testing for human epidermal growth factor receptor 2 gene amplification (item 73332), immunohistochemical examination (items 72849 and 72850), and certain tissue pathology items (items 72827, 72828, and 72838) to the list of pathologist-determinable services (Schedule 1, Item [2]). The Amendment Determination imposes specific obligations on the parties it governs, primarily those related to the classification and performance of pathology services. Approved Pathology Practitioners (APP) must ensure that any pathology service they perform without a treating practitioner’s request falls within the list of pathologist-determinable services as specified in the amended determination (subsection 4BA(1)). Additionally, APPs are required to ensure that their actions are in line with the criteria set out by the RCPA and the Health Insurance Act 1973, including the necessity of the service based on prior test results or the nature of the specimen (subsection 4BA(3)). This requirement ensures that the services rendered are justified and necessary for patient care. The Act outlines specific consequences for non-compliance with the provisions of the Amendment Determination. If a pathology service is performed that does not meet the criteria for being a pathologist-determinable service, Medicare benefits may not be payable for that service (subsection 16A(1), (3), and (6)). This lack of payment can result in financial implications for both the APP and the patient, as well as potential administrative scrutiny from Medicare. The Act does not specify a criminal penalty for non-compliance but emphasizes the importance of adhering to the listed criteria to ensure the correct payment of benefits and the provision of necessary services. The Amendment Determination also rectifies several errors found in the previous determination, such as incorrect item numbers and the omission of certain items that should have been listed as pathologist-determinable services. For instance, item 73332, which pertains to a genetic test for HER2 gene amplification in breast cancer patients, is now correctly listed as a pathologist-determinable service, and the incorrect item number for the detection of HLA-B27 by nucleic acid amplification has been corrected from 73220 to 73320. These amendments aim to ensure that the list of services is accurate and reflects the intended scope of the determination.