Health Insurance (Pathology Services Table) Amendment Regulations 2001 (No. 1) 2001 No. 4
EXPLANATORY STATEMENT
STATUTORY RULES 2001 No. 4
Issued by the Authority of the Minister for Health and Aged Care
Health Insurance Act 1973
Health Insurance (Pathology Services Table) Amendment Regulations 2001 (No. 1)
Section 133 of the Health Insurance Act 1973 (the Act) provides that the Governor-General may make regulations prescribing matters for the purpose of the Act.
The Act provides for the payment of professional services through Medicare benefits to all eligible persons.
Section 9 of the Act provides that Medicare benefits shall be calculated by reference to the fees for medical services (including pathology services) set out in the table.
Section 4A of the Act provides that a table of pathology services may be prescribed. The Health Insurance (Pathology Services Table) Regulations 2000, which commenced on 1 November 2000, prescribe such a table.
The Regulations implement a number of fee adjustments for selected pathology Medicare items to enable expenditure targets under the Pathology Quality and Outlays Agreement to be met. The growth trend in outlays for the second year of the agreement has risen to around 6.6%, considerably higher than the growth rate of 5.0% allowed. Under the terms of the agreement with the pathology industry, any over-expenditure can be brought back into line through Medicare item fee targeting.
Twenty-two pathology items have had a fee adjustment, of which fourteen have had a fee decrease and eight a fee increase. The items with a fee decrease are high volume common tests.
The overall effect of fee targeting is anticipated to decrease Pathology MBS expenditure equivalent to 1.01% of total expenditure for 1999/2000 or by $10.978m.
The changes to the 2000-2001 Pathology Services Table have been developed in cooperation with the two peak pathology professional bodies, the Royal College of Pathologists of Australasia and the Australian Association of Pathology Practices, through the Pathology Services Table Committee (PSTC).
Details of the Regulations are set out in the attachment.
The Regulations commenced on 7 February 2001.
ATTACHMENT
Regulation 1 cites the regulations as the Health Insurance (Pathology Services Table) Amendment Regulations 2001 (No. 1).
Regulation 2 prescribes a commencement date of 7 February 2001.
Regulation 3 provides for the Health Insurance (Pathology Services Table) Regulations 2000 to be amended as set out in Schedule 1.
The changes under Regulation 3, Schedule 1 are:
Medicare Item Number | Amended Fee |
66593 | 18.30 |
66596 | 33.10 |
66599 | 23.85 |
66602 | 43.45 |
66716 | 26.70 |
66719 | 36.40 |
66722 | 39.40 |
66725 | 52.40 |
66728 | 65.40 |
66731 | 78.40 |
66734 | 91.40 |
72813 | 70.00 |
73043 | 22.30 |
73045 | 47.50 |
73047 | 92.50 |
73049 | 67.50 |
73051 | 166.35 |
73053 | 19.00 |
73055 | 19.00 |
73057 | 19.00 |
73913 | 9.60 |
73915 | 9.60 |
Overview
The Health Insurance (Pathology Services Table) Amendment Regulations 2001 (No. 1) were enacted in 2001 to address the rising expenditure on pathology services under the Medicare Benefits Schedule (MBS). These Regulations, authorised by the Minister for Health and Aged Care, amend the Health Insurance (Pathology Services Table) Regulations 2000 to adjust fees for selected pathology services. The objective is to align the expenditure with the agreed growth rate of 5.0% as stipulated in the Pathology Quality and Outlays Agreement. This was necessary as the actual growth trend had risen to approximately 6.6%, exceeding the allowable rate. The adjustments involve decreasing fees for high volume common tests and increasing fees for others, aiming to reduce overall pathology MBS expenditure by 1.01% or $10.978 million for the year 1999/2000. The changes were developed in collaboration with key industry bodies to ensure balanced and fair adjustments.
Scope and Application
The Health Insurance (Pathology Services Table) Amendment Regulations 2001 (No. 1) apply to the Medicare system in Australia, specifically to pathology services covered under the Health Insurance Act 1973. These regulations govern the fees set for pathology services provided to eligible persons under the Medicare Benefits Schedule (MBS). The regulations target selected pathology items to adjust fees in order to meet the expenditure targets set under the Pathology Quality and Outlays Agreement. The amendments outlined in the regulations were developed in collaboration with key industry bodies to ensure that the adjustments are reasonable and effectively manage expenditure. The changes commenced on 7 February 2001 and are designed to reduce overall pathology expenditure by targeting fees on high-volume common tests, with fourteen items having a fee decrease and eight having a fee increase. The application of these regulations is confined to the pathology services listed in the amended table, and they do not extend beyond the scope of what is specified in the Health Insurance (Pathology Services Table) Regulations 2000.
Key Provisions
The primary operative sections of the Health Insurance (Pathology Services Table) Amendment Regulations 2001 (No. 1) are found in Regulation 3 and Schedule 1, which provide for amendments to the Health Insurance (Pathology Services Table) Regulations 2000. Regulation 3 outlines the amendments made to the pathology services table by adjusting the fees for selected pathology Medicare items. Schedule 1 provides a detailed list of the amendments, including the specific Medicare item numbers and the adjusted fees. These adjustments are designed to bring the growth trend in outlays for pathology services back within the expenditure targets set under the Pathology Quality and Outlays Agreement. The amendments include fee decreases for fourteen high volume common tests and fee increases for eight other items.
The obligations and requirements imposed by these Regulations are primarily on the providers of pathology services and the entities administering the Medicare Benefits Schedule (MBS). Pathology service providers must now charge the adjusted fees as prescribed in the amended table for the specified Medicare items. The Department of Health, as the entity administering the MBS, is required to ensure that these new fees are implemented and reflected in the processing of claims and payments. Additionally, the Regulations require ongoing cooperation and consultation with the relevant professional bodies, namely the Royal College of Pathologists of Australasia and the Australian Association of Pathology Practices, through the Pathology Services Table Committee (PSTC). These entities must work together to develop and review the pathology services table to ensure it meets the needs of the industry and aligns with expenditure targets.
Breaching the provisions of these Regulations can lead to several civil and criminal consequences. While the specific offences and penalties are not explicitly detailed in the explanatory statement, breaches of regulations concerning Medicare payments and services can generally result in financial penalties, legal action, or other administrative measures. Under the Health Insurance Act 1973, any person who makes a false or misleading claim for a benefit can be subject to fines and imprisonment. The exact penalties can vary based on the nature and severity of the breach, but they may include substantial fines, as well as potential criminal charges for serious or repeated offences. The Regulations aim to ensure compliance with the prescribed fees to maintain the integrity of the Medicare system and to achieve the intended expenditure targets.