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.
Overview
The Health Insurance (Pathologist-determinable Services) Determination 2005 (No. 2), enacted by the Commonwealth of Australia, was introduced to address the complexity and inefficiencies in the current pathology services framework, particularly concerning the need for additional requests from treating practitioners when further pathology tests are required. This determination was enacted by the Minister for Health under the authority of the Health Insurance Act 1973 and aims to streamline the process by allowing recognised pathologists to determine certain pathology services as necessary without requiring a new request from a treating practitioner. This change facilitates the timely and appropriate provision of pathology services, thereby improving patient outcomes and ensuring efficient use of Medicare benefits.
The determination addresses specific gaps by enabling Approved Pathology Practitioners to perform additional pathology services in certain circumstances without the need for a new request from a treating practitioner. For example, a specialist pathologist may perform additional tests on their own patients or when further tests are necessary following an initial request for another pathology service. The introduction of general antigen detection items, such as items 69364 and 69365, further supports best clinical practice by simplifying the current antigen item framework. The Royal College of Pathologists of Australasia was consulted in developing these changes, which were implemented to better align with clinical needs and reduce administrative burdens.
Scope and Application
The Health Insurance (Pathologist-determinable Services) Determination 2005 (No. 2) applies to pathology services and the approved pathology practitioners who render them, particularly specialist pathologists, within the framework of the Health Insurance Act 1973. This determination is designed to allow certain pathology services to be considered as pathologist-determinable services, which means that a request from a treating practitioner is not necessary to enable the payment of Medicare benefits. This applies to services rendered by an approved pathology practitioner to their own patients and services that the practitioner determines necessary following a request for another pathology service. The Act operates on a Commonwealth level, applying nationally across Australia. The exclusions or exemptions are limited to services that fall outside the specified pathologist-determinable services or those not performed under the circumstances outlined in the Determination. The application and scope of the Act can be extended or restricted through subordinate instruments, which would be detailed in the attached schedule or further legislative amendments.
Key Provisions
The Health Insurance (Pathologist-determinable Services) Determination 2005 (No. 2) introduces specific provisions under section 4BA of the Health Insurance Act 1973 (the Act) that allow certain pathology services to be considered as pathologist-determinable services. This means that the Minister can determine which pathology services can be covered by Medicare without requiring a separate request, provided they are rendered by an Approved Pathology Practitioner (APP) for their own patients or deemed necessary by the APP following a request from a treating practitioner. This determination aims to streamline the process and facilitate the payment of Medicare benefits in specific circumstances. The Royal College of Pathologists of Australasia has been consulted, as required by section 4BA of the Act.
Under section 16A of the Act, the payment of Medicare benefits for pathology services is contingent on certain requirements being met. Subsections 16A(1), (3), and (6) stipulate that a Medicare benefit is not payable unless the service was rendered pursuant to a request or is a pathologist-determinable service. The new determination provides clarity and flexibility in identifying which services fall under pathologist-determinable services, thus ensuring that the right services are covered by Medicare without unnecessary administrative burden.
The obligations imposed by this Act on the parties involved include the requirement for services to be rendered by an APP and for the services to be deemed necessary by the APP either for their own patients or following a request from a treating practitioner. The APP must ensure that the services fall within the defined categories of pathologist-determinable services as specified in the Determination. The APP must also adhere to the conditions set out in the Determination to ensure that Medicare benefits are appropriately applied.
There are no specific offences or penalties mentioned in the Determination itself, but any breach of the requirements set out in the Health Insurance Act 1973 could result in civil or criminal consequences. The penalties for non-compliance with the Act could include fines or other sanctions, depending on the nature and severity of the breach. The maximum penalties for such breaches are detailed elsewhere in the Act and could vary based on the specific circumstances of the non-compliance.