Health Insurance (Pathology Services Table) Amendment Regulations 2007 (No. 2)

Administered by Department of Health, Disability and Ageing

Legislation au F2007L00990 Regulations Not in force Legislative Instrument

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EXPLANATORY STATEMENT

 

Select Legislative Instrument 2007 No. 101

 

 Health Insurance Act 1973

 
 Health Insurance (Pathology Services Table) Amendment Regulations 2007
                       (No. 2)

 

Subsection 133 (1) of the Health Insurance Act 1973 (the Act) provides that the

Governor-General may make regulations, not inconsistent with the Act, prescribing all matters required or permitted by the Act to be prescribed, or necessary or convenient to be prescribed for carrying out or giving effect to the Act.

 

The Act provides, in part, 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.

 

Section 4A of the Act provides that the regulations may prescribe a table of pathology services that sets out items of pathology services, the amount of fees applicable in respect of each item, and rules for interpretation of the pathology services table.  The Health Insurance (Pathology Services Table) Regulations 2006 (the Principal Regulations) currently prescribe such a table. 

 

Subsection 4A(2) of the Act provides that, unless sooner repealed, regulations made under subsection 4A(1) cease to be in force and are taken to have been repealed on the day after the 15th sitting day of the House of Representatives after the end of a period of 12 months, commencing on the day on which the regulations are notified on the Federal Register of Legislative Instruments.  The 2006 Regulations were registered on the Federal Register of Legislative Instruments on  20 October 2006  and commenced on 1 November 2006.

 

The purpose of the changes is to amend the 2006 Regulations from 1 May 2007. 

The  changes add new items to support clinical best practice for biochemical and haematological tests.   The changes also add items for tests which are referred from one laboratory to another, unrelated laboratory, to remunerate the receiving laboratory appropriately; add items for the payment of an initiation of a patient episode fee for public laboratories; and include items to allow for the monitoring and evaluation of pilot testing sites under the Chlamydia Pilot Testing Program.

These changes have been developed with the co-operation and support of the three peak pathology bodies, the Royal College of Pathologists of Australasia, the Australian Association of Pathology Practices and the National Coalition of Public Pathology, through the Pathology Services Table Committee.

 

Details of the  Regulations are set out in the Attachment. 

 

The Act specifies no conditions that need to be satisfied before the power to make the  Regulations may be exercised.

 

The  Regulations are a legislative instrument for the purposes of the Legislative Instruments Act 2003.

 

The  Regulations commence on 1 May 2007.

 

ATTACHMENT

 

DETAILS OF THE HEALTH INSURANCE (PATHOLOGY SERVICES TABLE) AMENDMENT REGULATIONS 2007 (No. 2)

 

Regulation 1 – Name of Regulations

 

This regulation provides for the Regulations to be referred to as the Health Insurance (Pathology Services Table) Amendment Regulations 2007 (No. 2).

 

Regulation 2 – Commencement

 

This regulation provides for the Regulations to commence on 1 May 2007.

 

Regulation 3 – Amendment

 

This regulation provides that Schedule 1 amends the Health Insurance (Pathology Services Table) Regulations 2006,the Principal Regulations.

 

Schedule 1 – Amendments

 

Schedule 1 sets out a number of changes to the following provisions in Schedule 1 to the Principal Regulations:

  • Part 2 – Rules of interpretation;
  • Part 3 – Services and fees;
  • Part 4 – Abbreviations; and
  • Part 5 – Complexity Levels for Histopathology items.

 

Part 2 - Rules of interpretation

 

Items [1] to [15] of the Regulations incorporate the following changes:

 

Rules 1, 4, 6, 14, 15, 16, 18, 19, 20, 22, 25, 26 and 27 have been changed.  These changes are to reflect the addition of new items; to support clinical best practice for biochemical and haematological tests; for tests which are referred from one laboratory to another, unrelated laboratory, to remunerate the receiving laboratory appropriately; for the payment of an initiation of a patient episode initiation fee for public laboratories; and to allow for the monitoring and evaluation of pilot testing sites under the Chlamydia Pilot Testing Program have been added.

 

New subrule 18A (2) provides a description of a set of pathology services in relation to Rule 18.  

 

New subrule 18A (3) provides a list of items to be excluded from a set of pathology services in relation to Rule 18.

 

Part 3 – Services and fees

 

Items [16] to [42] of the Regulations incorporate the following changes:

 

The addition of four new items to support clinical best practice in biochemistry and haematology (65109, 65110, 66756 and 66757).

 

The addition of nine new Patient Episode Initiation items for public laboratories (73923, 73925, 73927, 73929, 73931, 73933, 73935, 73937 and 73939).   

 

The introduction of 62 new items for tests which are referred to a laboratory other than the laboratory which received the original request for pathology services (65079, 65082, 65157, 65158, 65166, 65180, 65181, 66606, 66609, 66639, 66642, 66651, 66652, 66663, 66666, 66696, 66697, 66714, 66715, 66723, 66724, 66780, 66783, 66789, 66790, 66792, 66804, 66805, 66816, 66817, 66820, 66821, 66826, 66827, 69325, 69328, 69331, 69379, 69383, 69400, 69401, 69419, 69451, 69489, 69492, 69497, 69498, 69500, 71076, 71090, 71092, 71096, 71148, 71154, 71156, 71169, 71170, 73309, 73312, 73315, 73318 and 73321). There has also been significant renumbering of existing items to accommodate the new items.

 

The addition of three new items for the detection of Chlamydia Trachomatis (69316, 69317, and 69319).

 

 

Part 4 – Abbreviations

 

There has been significant renumbering of the item numbers attached to the abbreviations to reflect the nine new Patient Episode Initiation items, the 62 new items allowing for tests to be referred and the renumbering of items within Part 3 of the Schedule to accommodate these new items.  

 

 

Part 5 – Complexity Levels

 

Five new complexity levels have been added.

 

Anus, submucosal resection – neoplasm     5             

Large bowel (including rectum), submucosal resection - neoplasm     5

Oesophagus, submucosal resection - neoplasm     5

Small bowel, submucosal resection - neoplasm     5

Stomach, submucosal resection - neoplasm     5

 

 

 

 

 

 

Overview

The Health Insurance Act 1973, enacted by the Parliament of Australia, provides for the payment of Medicare benefits for professional services rendered to eligible persons. Specifically, it mandates that Medicare benefits be calculated by reference to the fees for medical services, including pathology services, set out in prescribed tables. To this end, the Health Insurance (Pathology Services Table) Amendment Regulations 2007 (No. 2) were introduced to amend the Health Insurance (Pathology Services Table) Regulations 2006, in order to update the table of pathology services. These amendments aimed to incorporate new items that support clinical best practice for biochemical and haematological tests, provide appropriate remuneration for tests referred from one laboratory to another, and facilitate the payment of an initiation of a patient episode fee for public laboratories. Additionally, the changes included items to monitor and evaluate pilot testing sites under the Chlamydia Pilot Testing Program. The amendments were developed with the collaboration of peak pathology bodies, ensuring that the updated table reflects contemporary clinical practices and requirements. The Health Insurance (Pathology Services Table) Amendment Regulations 2007 (No. 2) were made under the authority provided by subsection 133(1) of the Health Insurance Act 1973, which allows the Governor-General to make regulations not inconsistent with the Act. These regulations commenced on 1 May 2007 and are a legislative instrument for the purposes of the Legislative Instruments Act 2003. The changes introduced by these amendments aim to align the pathology services table with current clinical needs and practices, ensuring that the Medicare benefits system remains effective and responsive to the evolving healthcare landscape.

Scope and Application

The Health Insurance (Pathology Services Table) Amendment Regulations 2007 (No. 2) amends the Health Insurance (Pathology Services Table) Regulations 2006 to update the table of pathology services fees and rules for interpretation. These amendments apply to the pathology services provided to eligible persons under the Health Insurance Act 1973, ensuring the fees for medical services, including pathology services, are accurately calculated and paid in accordance with the prescribed tables. The regulations are applicable across Australia as they pertain to Medicare benefits, which are federally administered. There are no specific exclusions or thresholds mentioned in the explanatory statement, but the changes primarily focus on updating and expanding the services covered, such as adding new items for biochemical and haematological tests, tests referred between laboratories, and fees for the initiation of patient episodes in public laboratories. The regulations are made under the authority of the Health Insurance Act 1973 and come into effect on 1 May 2007.

Key Provisions

The Health Insurance (Pathology Services Table) Amendment Regulations 2007 (No. 2) amend the Health Insurance (Pathology Services Table) Regulations 2006 (Principal Regulations), as specified in Schedule 1 of the Amendment Regulations. These amendments are intended to update and enhance the pathology services table to better reflect clinical best practices and address specific needs in the pathology sector. Under section 4A(2) of the Health Insurance Act 1973, the regulations specify a table of pathology services, the applicable fees, and rules for interpreting the table. These amendments, which commence on 1 May 2007, introduce new items and rules to the existing table, including additional services for biochemical and haematological tests, fees for tests referred from one laboratory to another, and fees for the initiation of patient episodes in public laboratories. Furthermore, the amendments introduce new items for the detection of Chlamydia Trachomatis and include provisions for monitoring and evaluating pilot testing sites under the Chlamydia Pilot Testing Program. The obligations under these regulations primarily concern medical service providers, laboratories, and public health institutions that provide pathology services and bill Medicare for these services. Service providers must adhere to the updated fees and rules outlined in the amended table, ensuring that the correct fees are applied for the specified pathology services. Laboratories involved in the referral of tests must correctly identify and bill for referred tests using the new item numbers. Public laboratories must also correctly identify and bill for the initiation of patient episodes using the new item numbers. Additionally, all parties involved in the detection and monitoring of Chlamydia Trachomatis must comply with the new items introduced for this purpose. Breach of the provisions outlined in these regulations can result in various civil and criminal consequences. While specific penalties are not detailed in the explanatory statement, non-compliance with Medicare billing regulations generally can lead to fines, recovery of overpaid benefits, and potential criminal charges in cases of fraud or wilful misrepresentation. The penalties can vary depending on the severity and intent of the breach, with potential fines and imprisonment for serious offences. It is essential for all parties to ensure compliance with these regulations to avoid any legal repercussions.

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