Health Insurance (Pathology Services Table) Amendment Regulations 2008 (No. 1)

Administered by Department of Health, Disability and Ageing

Legislation au F2008L00490 Regulations Not in force Legislative Instrument

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EXPLANATORY STATEMENT

 

Select Legislative Instrument 2008 No. 32

 

Subject -  Health Insurance Act 1973

  

 Health Insurance (Pathology Services Table) Amendment Regulations 2008 (No. 1)

 

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 2007 (the Principal Regulations) currently prescribe such a table. 

 

The Regulations amend the current table of pathology services in the Principal Regulations, as part of the ongoing management of the table. The changes consist of revised clinical descriptors for existing haematological and microbiology tests and a consequent amendment to rule 11 to reflect the changes to the haematological and microbiology items; a minor amendment to rule 4 clarifying restrictions to be applied to two haematology items; an amendment to rule 13 to include bone marrow biopsies; a minor amendment to rule 18 excluding testing for hepatitis B and C from certain restrictions; a fee reduction for two haematological items to compensate for an anticipated slight increase in utilisation of two immunochemistry items for bone marrow biopsies; and an equalisation of fees (at no cost) for related pregnancy and non-pregnancy serology items in microbiology.

 

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 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 2008.


 

ATTACHMENT

 

 

DETAILS OF THE HEALTH INSURANCE (PATHOLOGY SERVICES TABLE) AMENDMENT REGULATIONS 2008 (No. 1)

 

Regulation 1 – Name of Regulations

 

This regulation provides for the Regulations to be referred to as the Health Insurance (Pathology Services Table) Amendment Regulations 2008 (No. 1).

 

Regulation 2 – Commencement

 

This regulation provides for the Regulations to commence on 1 May 2008.

 

Regulation 3 – Amendment of  the Health Insurance (Pathology Services Table) Regulations 2007

 

This regulation provides that Schedule 1 amends the Health Insurance (Pathology Services Table) Regulations 2007, 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 2 - Rules of interpretation

 

Items [1] to [4]

Rule 4 provides exemptions to rule 3 which places a limit on the benefits payable during a single patient episode.  It is amended to add an exemption for haematology items 65109 and 65110.

 

Rule 11 lists the specific rules that apply to the payment of benefits for tests for the investigation of a patient’s blood serum to check the level of protection against hepatitis. It  is amended to reflect changes made in the Table to various hepatitis item descriptors and to simplify the rule.  

 

Rule 13 provides the definition of tissue pathology and is amended to include bone marrow biopsy which had been specifically excluded.  This is amended to ensure clinical best practice in tissue pathology for bone marrow biopsies.

 

Rule 18 limits the benefits payable to a total of three items with the highest fee in a patient episode.  There are a number of exemptions to this rule included in rule 18A and the test for hepatitis B and C antibodies (69484) is added as an exemption.

 

 

 

 

 

Part 3 – Services and fees

 

Items [5] to [10]

Haematology item descriptors 65078, 65081, 65084, 65087 and microbiology item descriptors 69378, 69475, 69478, 69481 and 69494 is simplified to allow pathologists to provide clinical best practice when undertaking these tests.

 

There is a fee reduction for two haematology items for bone marrow biopsies (65084 and 65087) to compensate for an anticipated slight increase in utilisation of two tissue pathology items for bone marrow biopsies (72846 and 72847) as a result of a change to rule 13 above.

 

The fees for pregnancy and non-pregnancy serology items in microbiology are equalised to recognise that an equal amount of work is required.  Fees  are amended in items 69387, 69390, 69393, 69396, 69399, 69401, 69408, 69411, 69413 and 69415.  Some fees are increased and some are reduced so it is cost-neutral overall.

 

Overview

The Health Insurance (Pathology Services Table) Amendment Regulations 2008 (No. 1) were enacted under the authority of the Health Insurance Act 1973 to address the need for updates and refinements in the pathology services table, which is used to calculate Medicare benefits for pathology services. The Act, enacted by the Parliament of Australia, provides for payments of Medicare benefits for professional services rendered to eligible persons, and section 9 mandates that these benefits be calculated by reference to the fees for medical services set out in prescribed tables. These Regulations were developed in consultation with 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, aiming to ensure that the services and fees align with clinical best practices and anticipated changes in service utilisation. The Regulations, which commenced on 1 May 2008, include amendments to the clinical descriptors of existing haematological and microbiology tests, adjustments to the rules governing the interpretation of the table, and modifications to the fees for certain services to ensure that they accurately reflect the work involved and anticipated changes in service demand.

Scope and Application

The Health Insurance (Pathology Services Table) Amendment Regulations 2008 (No. 1) pertain to the Health Insurance Act 1973, which governs the payment of Medicare benefits for professional services rendered to eligible individuals. These regulations specifically address the Pathology Services Table, detailing the fees for pathology services and the rules for interpreting these fees. The amendments introduced by these regulations aim to refine clinical descriptors for certain haematological and microbiology tests, adjust the fees accordingly, and update the rules to better align with clinical best practices and anticipated changes in service utilisation. The regulations apply to all entities and individuals involved in providing pathology services under the Health Insurance Act, including pathology laboratories and healthcare providers. They have a national reach across Australia, as the Health Insurance Act operates at a Commonwealth level. The regulations commence on 1 May 2008, and no specific exclusions or thresholds are mentioned in the text provided. The regulations are made under the authority granted by the Health Insurance Act and are subject to the legislative framework established by the Legislative Instruments Act 2003.

Key Provisions

The Health Insurance (Pathology Services Table) Amendment Regulations 2008 (No. 1) primarily amend the existing Health Insurance (Pathology Services Table) Regulations 2007, under Section 4A of the Health Insurance Act 1973 (the Act). These regulations introduce a revised table of pathology services, updating clinical descriptors for haematological and microbiology tests, and modifying associated fees and rules. For instance, Regulation 3 amends the Principal Regulations to include bone marrow biopsies in the definition of tissue pathology (Rule 13) and clarifies restrictions on two specific haematology items (Rule 4). Additionally, it introduces an exemption for hepatitis B and C antibody tests from certain benefit restrictions (Rule 18A). These amendments impose specific obligations on medical service providers and pathology practices to ensure compliance with the updated fee schedule and clinical descriptors. Medical professionals must now adhere to the revised clinical descriptors and fee adjustments as stipulated in the amended regulations. Moreover, pathology practices must ensure that their billing practices reflect these changes to avoid discrepancies in Medicare benefit payments. The regulations also require the Pathology Services Table Committee to regularly review and update the pathology services table, maintaining its relevance to clinical best practices and evolving medical needs. Failure to comply with these regulations may result in penalties under the Health Insurance Act 1973. Specifically, Section 133(1) of the Act allows for penalties where regulations are not adhered to, potentially including fines or other enforcement actions. While the specific penalties are not detailed in the explanatory statement, the general penalties for non-compliance with Medicare regulations can include substantial financial penalties and legal action, reflecting the seriousness with which such breaches are treated under Australian law. The amendments also introduce specific fee adjustments, including reductions and equalisations, to ensure a fair and cost-neutral application of the changes. For instance, the reduction in fees for certain haematology items aims to compensate for an anticipated increase in the use of related tissue pathology items. This adjustment is intended to maintain economic balance within the pathology services sector. Any deviation from these specified fees could potentially lead to disputes over Medicare benefits, highlighting the importance of strict compliance with the updated fee schedule.

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