Health Insurance (Pathology Services Table) Amendment Regulations 2002 (No. 1) 2002 No. 77
EXPLANATORY STATEMENT
Statutory Rules 2002 No. 77
Issued by the authority of the Minister for Health and Ageing
Health Insurance Act 1973
Health Insurance (Pathology Services Table) Amendment Regulations 2002 (No. 1)
Section 133 of the Health Insurance Act 1973 (the Act) provides that the Governor-General may make regulations prescribing matters for the purposes of the Act.
Section 10 of the Act provides for payments of Medicare benefits in respect of professional services rendered to 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 prescribed tables.
Subsection 4A of the Act provides that the table of pathology services may be prescribed in regulations. The Health Insurance (Pathology Services Table) Regulations 2001 prescribes such a table.
The purpose of the amendment to the Health Insurance (Pathology Services Table) Regulations 2001 is to amend five existing items, delete two items and include a new complexity level for histopathology items.
The overall effect of the proposed changes is anticipated to have no major financial implications and can be incorporated within the expenditure targets under the Pathology Quality and Outlays Agreement.
The change's have been developed with the co-operation and support of the two peak pathology bodies, the Royal College of Pathologists of Australasia (RCPA) and the Australian Association of Pathology Practices (AAPP), through the Pathology Services Table Committee and the Pathology Consultative Committee.
Details of the amendments are provided at the Attachment.
The amendments commenced on gazettal.
ATTACHMENT
Regulation 1 cites the regulations as the Health Insurance (Pathology Services Table) Amendment Regulations 2002 (No. 1).
Regulation 2 prescribes a commencement date of gazettal.
Regulation 3 prescribes the amendments to the Health Insurance (Pathology Services Table) Regulations 2001.
The changes under Regulation 3, Schedule 1 are:
• Removal of the reference to electrophoresis from general chemistry item 66500. The electrophoresis technique is now appropriately covered under a number of other items.
• Amendment of drugs of abuse item 66626 to allow for 36 tests in a 12 month period in line with current practice. The item currently allows for 21 tests in a 12 month period. The Pathology Services Table Committee received advice on this matter from a number of groups that conduct drug treatment programs indicating that most programs run for at least 3 months with a follow up maintenance period. Testing is generally 3 times per week for the first 3 months (36 tests).
• Amendment to Prostate Specific Antigen (PSA) item 66655 to remove ambiguity and confusion created by the phrase 'clinically suspected prostatic disease' in the item descriptor. The original intention for this item was that the decision to order a PSA test to be at the discretion of the treating practitioner who may consider such indications as age or family history, rather than obvious clinical symptoms, as an appropriate reason to request the test for a patient.
• A minor amendment to faeces culture item 69345 to further clarify specimen
collection requirements.
• The removal of the words 'including serial dilution (if performed)' from the Human chorionic gonadotrophin (HCG) pregnancy item 73527, as this test is considered to be outdated.
• A new complexity level for 'Small bowel - biopsy, all sites (complexity 4)'.
• Deletion of items 65139 (quantitation of plasminogen) and 65140 (quantitation of euglobulin clot lysis time), following consistently low utilisation and limited clinical application.
Overview
The Health Insurance (Pathology Services Table) Amendment Regulations 2002 (No. 1) were enacted to refine and update the existing Health Insurance (Pathology Services Table) Regulations 2001 under the authority of the Minister for Health and Ageing. These amendments aim to address issues of outdated practices, clarify item descriptors, and respond to the evolving needs in pathology services. The amendments were developed in collaboration with key pathology bodies, the Royal College of Pathologists of Australasia and the Australian Association of Pathology Practices, ensuring that the changes are grounded in current clinical practices and reflect the consensus of the relevant professional groups. This legislative update seeks to maintain the accuracy and relevance of the Medicare benefits system by ensuring that the pathology services table aligns with contemporary medical practices and the needs of the healthcare system.
The regulations, which came into effect upon gazettal, modify the existing table by removing outdated practices, updating test allowances, and refining the descriptors of certain items to eliminate ambiguity. For instance, the amendments include the removal of the electrophoresis reference from general chemistry and updating the allowable number of drug abuse tests per year. Additionally, the regulations introduce a new complexity level for histopathology items and remove items with low utilisation rates. The overall goal of these amendments is to streamline the pathology services table, ensuring it remains a practical and efficient tool for the administration of Medicare benefits, without incurring significant financial implications.
Scope and Application
The Health Insurance (Pathology Services Table) Amendment Regulations 2002 (No. 1) amends the Health Insurance (Pathology Services Table) Regulations 2001 to update the fees and descriptors for certain pathology services under the Health Insurance Act 1973. These amendments apply to the pathology services listed in the Pathology Services Table, which determine the Medicare benefits payable for these services rendered to eligible persons. The regulations are made under section 4A of the Act, which allows the Governor-General to prescribe the table of pathology services through regulation. The amendments, which include modifications to five existing items, the deletion of two items, and the introduction of a new complexity level for a histopathology item, were developed with the input of relevant professional bodies. The changes are intended to reflect current practice and remove outdated or ambiguous items, with the overall financial impact anticipated to be minor and within existing expenditure targets. These amendments apply nationally and commenced on the date of gazettal.
Key Provisions
The Health Insurance (Pathology Services Table) Amendment Regulations 2002 (No. 1) (the Regulations) provide amendments to the fees for pathology services under the Health Insurance Act 1973 (the Act). Regulation 3 of the Regulations details the amendments to the Health Insurance (Pathology Services Table) Regulations 2001. These amendments involve modifying existing items, deleting certain items, and introducing a new complexity level for specific pathology services. For example, the amendments remove the reference to electrophoresis from general chemistry item 66500, update the drugs of abuse item 66626 to allow for 36 tests in a 12-month period, and clarify the Prostate Specific Antigen (PSA) item 66655 by removing ambiguous language. Additionally, the Regulations introduce a new complexity level for 'Small bowel - biopsy, all sites (complexity 4)' and delete items 65139 and 65140 due to low utilisation and limited clinical application.
The Regulations impose obligations on pathology service providers and medical practitioners to adhere to the updated fees and descriptors for pathology services as prescribed. Providers must ensure that their billing practices conform to these changes, while practitioners need to be aware of the updated criteria and limitations for certain tests, such as the number of drug abuse tests permitted within a specified period. The amendments aim to streamline pathology service billing and ensure that the fees reflect current clinical practices and technological advancements.
Breaches of the Regulations, particularly non-compliance with the updated fees and descriptors, may result in financial penalties or disputes over the validity of claims for Medicare benefits. While the explanatory statement does not detail specific penalties, it is likely that the Health Insurance Act 1973 and associated administrative guidelines would provide for fines or other corrective measures for non-compliance. Given the collaborative development of these amendments with relevant professional bodies, it is expected that adherence to the Regulations is crucial for maintaining the integrity of the Medicare system and ensuring fair and accurate billing practices.