EXPLANATORY STATEMENT
HEALTH INSURANCE ACT 1973
SECTION 4BA
HEALTH INSURANCE (PATHOLOGIST-DETERMINABLE SERVICES)
DETERMINATION 2005
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, in light of results obtained from earlier tests performed in response to a request from the requesting practitioner.
An example of the former is a haematologist or immunologist performing pathology services on their own patients. An example of the latter is the receipt of a request by a histopathologist for the examination of a biopsy specimen from an operation and following examination, determine 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 73305 (the southern blot for detection of fragile X mutation) as a pathologist determinable test. This will clarify that the APP does not require a separate request to do this test when the results of the nucleic acid amplification test for the detection of fragile X mutation is inconclusive. Therefore item 73305 is considered pathologist determinable following a request for item 73300.
The following tests are identified as pathologist-determinable–
- 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.
The commencement date for the new determination is 1 May 2005.
Tony Abbott
Overview
The Health Insurance (Pathologist-Determinable Services) Determination 2005, enacted by the Commonwealth of Australia under the authority of the Health Insurance Act 1973, was introduced to address the need for flexibility in the payment of Medicare benefits for pathology services. The Health Insurance Act 1973, enacted by the Australian Parliament, governs the provision of health insurance benefits, including Medicare. The policy objective of this determination is to ensure that certain pathology services can be performed and reimbursed without the necessity of a formal request from a treating practitioner, thus allowing for a more streamlined and efficient process where the services are deemed necessary by an Approved Pathology Practitioner (APP) in the interest of the patient. This determination was made following consultations with the Royal College of Pathologists of Australasia, as mandated by the Act, to ensure that the services designated as pathologist-determinable appropriately reflect the clinical needs and practices of pathology services.
Scope and Application
The Health Insurance (Pathologist-Determinable Services) Determination 2005 applies to approved pathology practitioners, specifically specialist pathologists, within the Commonwealth of Australia. This legislative instrument allows these practitioners to perform additional pathology services without the necessity of a formal request from a requesting practitioner under certain conditions. This application is made in accordance with section 4BA of the Health Insurance Act 1973, which enables the Minister to classify specific pathology services as pathologist-determinable, after consultation with relevant professional bodies like the Royal College of Pathologists of Australasia. The primary purpose of this determination is to streamline the process and ensure that Medicare benefits are payable for services rendered in specific circumstances, such as when the services are performed for the practitioner's own patients or when further tests are necessary following initial examination of results. The scope of the Act is therefore directed towards enhancing the efficiency and efficacy of pathology services by reducing administrative burdens while ensuring appropriate coverage under the Medicare system.
Key Provisions
Section 4BA of the Health Insurance Act 1973 (the Act) allows the Minister to designate certain pathology services as pathologist-determinable. This means that these services can be performed by an Approved Pathology Practitioner (APP) without the need for a specific request from another practitioner, provided the APP deems it necessary in the patient’s interest. For example, a specialist like a haematologist or immunologist can perform pathology services for their own patients without needing a separate request. Another instance is when a histopathologist identifies the need for further tests after examining a biopsy specimen, without having to seek another request from the treating practitioner.
Under section 16A of the Act, certain conditions must be fulfilled for Medicare benefits to be paid for pathology services. Specifically, subsections 16A(1), (3), and (6) stipulate that a Medicare benefit is not payable for a pathology service unless it was requested or it is a pathologist-determinable service. This determination aims to streamline the process and cover specific circumstances where a service is performed by an APP for their own patients or deemed necessary based on previous test results.
The obligations imposed on the parties governed by this Act include ensuring that any pathology services designated as pathologist-determinable are performed by an APP and are necessary in the patient’s interest. APPs must adhere to the criteria outlined in the Act and the specific determinations made by the Minister. The Royal College of Pathologists of Australasia has been consulted in this process, ensuring that the determinations are made with expert input.
Failure to comply with the requirements of the Act can lead to significant consequences. While the explanatory statement does not detail specific offences or penalties, breaches of Medicare payment rules generally can result in substantial fines and other legal actions. For example, non-compliance with Medicare regulations can lead to civil penalties, including financial penalties, and in some cases, criminal charges. The maximum penalties for such breaches can be severe, depending on the nature and extent of the non-compliance.