EXPLANATORY STATEMENT
HEALTH INSURANCE ACT 1973
SECTION 4BA
HEALTH INSURANCE (PATHOLOGIST-DETERMINABLE SERVICES)
DETERMINATION 2005 (No. 2)
Section 4BA of the Health Insurance Act 1973 (the Act) provides for the Minister to determine that a particular pathology service, or pathology services included in a class of pathology services, be considered as pathologist-determinable services. The Royal College of Pathologists of Australasia have been consulted on this process, as required by section 4BA of the Act.
Section 16A of the Act specifies that certain requirements have to be met for the payment of Medicare benefits in relation to pathology services. Subsections 16A(1), (3) and (6) provide that a Medicare benefit is not payable in respect of a pathology service unless the service was rendered pursuant to a request or is a pathologist-determinable service.
The purpose of the pathologist-determinable services determination is to obviate the need for a request and allow for the payment of Medicare benefits to cover specific circumstances where:
- services are requested and performed by an Approved Pathology Practitioner (APP) such as a specialist pathologist, for their own patients; and
- services which an APP has deemed necessary to perform in the interest of the patient, following a request from a treating practitioner for another pathology service.
An example of the former is a haematologist or immunologist performing pathology services on their own patients. An example of the latter is a histopathologist receiving a request from a treating practitioner for the examination of a biopsy specimen from an operation and, following the examination, the histopathologist determines that further tests are necessary to complete the diagnosis. The histopathologist would be able to undertake further testing without the need to seek another request from the treating practitioner.
Pathologists have identified a need to create item 69364 and 69365 (antigen detection items) as pathologist determinable tests. Items 69364 and 69365 are considered pathologist determinable if a recognised pathologist determines the service to be necessary based on information provided by the requesting practitioner, the nature or appearance of the specimen, or as a consequence of information resulting from a pathology service mentioned in items 69303, 69306, 69312, 69318, 69321 or 69345. The two general antigen detection items will decrease the complexity that is developing within the current antigen item and support best clinical practice. This addition is the only substantial difference between the Determination and the Health Insurance (Pathologist-determinable Services) Determination 2005, which the Determination revokes and replaces.
The proposed changes have been developed with the co-operation and support of the Royal College of Pathologists of Australasia (RCPA) through the Pathology Services Table Committee.
Details of the Determination are set out in the Attachment.
The commencement date for the new determination is 1 November 2005.
ATTACHMENT
Details of the Health Insurance (Pathologist-determinable Services) Determination 2005 (No 2)
Item 1 provides for the Determination to be referred to as the Health Insurance (Pathologist-determinable Services) Determination 2005 (No.2)
Item 2 provides for the Determination to commence on 1 November 2005.
Item 3 provides for the Determination to revoke the Health Insurance (Pathologist-determinable Services) Determination 2005 made on 5 April 2005.
Item 4 defines “Act”, “Regulations” and “recognised pathologist” for the purposes of the Determination.]
Item 5 provides that the following items in the pathology services table are, when rendered in the circumstances described in the Determination, classes of pathology services that are pathologist-determinable services:
- an item in the pathology services table that is rendered, by or on behalf of, an approved pathology practitioner to a patient of that practitioner;
- items 72846 or 72847 or 72848 following a request for items 72813 – 72836,
- items 73059 or 73060 or 73061 following a request for items 73045 – 73051,
- items 72851 or 72852 following a request for items 72813 – 72836,
- item 73305 following a request for item 73300,
- items 63964 or 69365 following a request for items 69303, 69306, 69312, 69318, 63921 or 69345.