Health Insurance (Pathology Services Table) Amendment Regulations 2009 (No. 2)

Administered by Department of Health, Disability and Ageing

Legislation au F2009L01726 Regulations Not in force Legislative Instrument

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EXPLANATORY STATEMENT

 

Select Legislative Instrument 2009 No. 114

 

Health Insurance Act 1973

 

Health Insurance (Pathology Services Table) Amendment Regulations 2009 (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 2008 (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 purpose of the changes is to increase fees for a small number of high complexity items in Group P5 - Tissue Pathology, which are currently under-remunerated.  These items require a high level of professional input and the increase in fees reflects the costs associated with performing examinations on tissue samples and the reporting of these pathology tests.  The increases are offset by small fee reductions to a large number of more automated, high volume tests elsewhere in the table.

 

A number of amendments to descriptors for other items are also being made.  These amendments clarify the conditions for claiming these items.

 

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.  They have been discussed and agreed by 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 July 2009.

 

  Authority: Subsection 133(1) of the

    Health Insurance Act 1973

 

ATTACHMENT

 

DETAILS OF THE HEALTH INSURANCE (PATHOLOGY SERVICES TABLE) AMENDMENT REGULATIONS 2009 (NO. 2)

 

1  Name of Regulations

 

This regulation provides for the Regulations to be referred to as the Health Insurance (Pathology Services Table) Amendment Regulations 2009 (No. 2).

 

2  Commencement

 

This regulation provides that the Regulations commence on 1 July 2009.

 

3  Amendment of the Health Insurance (Pathology Services Table) Regulations 2008

 

This regulation provides that Schedule 1 amends the Health Insurance (Pathology Services Table) Regulations 2008, the Principal Regulations.

 

Schedule 1  Amendments

 

Item [1]

The following items have schedule fee decreases of between $0.05 and $2.30 applied to offset the cost of the increase to tissue pathology schedule fees:

 

65060, 65066, 65070, 65072, 65075, 65078, 65079, 65081, 65082, 65090, 65093, 65096, 65099, 65102, 65105, 65108, 65109, 65110, 65111, 65114, 65117, 65120, 65123, 65126, 65129, 65137, 65142, 65144, 65147, 65150, 65153, 65156, 65157, 65158, 65159, 65162, 65165, 65166, 65171, 65175, 65176, 65177, 65178, 65179, 65180, 65181, 66517, 66518, 66519, 66536, 66539, 66542, 66545, 66548, 66551, 66554, 66557, 66560, 66563, 66566, 66569, 66572, 66575, 66578, 66581, 66584, 66587, 66590, 66593, 66596, 66599, 66602, 66605, 66606, 66608, 66609, 66623, 66626, 66629, 66632, 66635, 66638, 66639, 66641, 66642, 66644, 66647, 66650, 66651, 66652, 66653, 66655 and 66656.

 

Items 65084 and 65087 have schedule fee increases of $3.25 and $4.15 respectively applied to ensure appropriate fee relativities are maintained.

 

Item [2] to [4]

Items 66659 and 66660 are amended to specify that the follow-up test result could lie at the relevant reference level, rather than having to be above it.  This clarifies when these items should be claimed.

 

Item 66659 also has a schedule fee decrease to offset cost of the increase to tissue pathology schedule fees.

 

Item [5]

The following items have schedule fee decreases of between $0.10 and $4.60 applied to offset the cost of the increase to tissue pathology schedule fees:

 

66659, 66662, 66663, 66665, 66666, 66667, 66671, 66674, 66677, 66680, 66683, 66686, 66711, 66712, 66714, 66715, 66716, 66719, 66722, 66723, 66724, 66725, 66728, 66731, 66734, 66743, 66749, 66750, 66751, 66752, 66755, 66756, 66757, 66758, 66761, 66764, 66767, 66770, 66773, 66776, 66779, 66780, 66782, 66783, 66785, 66788, 66789, 66790, 66791, 66792, 66800, 66803, 66804, 66805, 66806, 66812, 66815, 66816, 66817, 66819, 66820, 66821, 66822, 66825, 66826, 66827, 66828, 66830, 71057, 71058, 71059, 71060, 71062, 71064, 71066, 71068, 71069, 71071, 71072, 71073, 71074, 71075, 71076, 71077, 71079, 71081, 71083, 71085, 71087, 71089, 71090, 71091, 71092, 71093, 71095, 71096, 71097, 71099, 71101, 71103, 71106, 71119, 71121, 71123, 71125, 71127, 71129, 71131, 71133, 71134, 71135, 71137, 71139, 71141, 71143, 71145, 71146, 71147, 71148, 71149, 71151, 71153, 71154, 71155, 71156, 71157, 71159, 71163, 71164, 71165, 71166, 71167, 71168, 71169, 71170, 71180, 71183, 71186, 71189, 71192, 71195, 71198, 71200 and 71203.

 

Items 72830, 72836, 72838, 72846, 72847, 72848, 72849 and 72850 have schedule fee increases applied to better reflect the cost of performing and reporting tissue pathology services.

 

Item [6]

Item 73059 is amended to indicate that examination could include material obtained by fine needle aspiration where an employee of the Approved Pathology Practitioner also attends the aspiration (item 73063).  This allows greater quality of material examined under this item.

 

Item [7]

Items 73060 and 73061 is amended to indicate that examination could include material obtained by fine needle aspiration where an employee of the Approved Pathology Practitioner also attends the aspiration (item 73063).  This allows greater quality of material examined under these items.

 

Item [8]

Items 73064 and 73065 are amended to indicate that examination could include material obtained by fine needle aspiration where an employee of the Approved Pathology Practitioner also attends the aspiration (item 73063).  This allows greater quality of material examined under these items.

 

Item [9]

The following items have schedule fee decreases of between $0.05 and $4.25 applied to offset the cost of the increase to tissue pathology schedule fees:

 

73287, 73289, 73300, 73305, 73308, 73309, 73311, 73312, 73314, 73315, 73317, 73318, 73320, 73321, 73323, 73521, 73523, 73525, 73527 and 73529.

 

 

Overview

The Health Insurance (Pathology Services Table) Amendment Regulations 2009 (No. 2) were enacted to address the issue of under-remuneration of pathology services within the Medicare system, particularly for high complexity items. This regulation, enacted by the Parliament of Australia, is an amendment to the Health Insurance Act 1973 and aims to ensure that the fees for pathology services accurately reflect the costs associated with providing these services. The primary policy objective of these amendments is to enhance the quality and accuracy of pathology services by adjusting the fees for certain items, while maintaining overall budget neutrality through adjustments to other items. These changes were developed in collaboration with key pathology bodies and have been reviewed by the Pathology Services Table Committee to ensure they meet the needs of the healthcare sector and the public.

Scope and Application

The Health Insurance (Pathology Services Table) Amendment Regulations 2009 (No. 2) applies to the pathology services table under the Health Insurance Act 1973, which governs payments of Medicare benefits for pathology services rendered to eligible persons. The Act applies across the Commonwealth of Australia and the Regulations amend the current table of pathology services to ensure appropriate fee relativities, reflecting the professional input and costs associated with performing and reporting on pathology tests. The amendments increase fees for a small number of high complexity pathology items, while offsetting these increases with fee reductions to a larger number of more automated, high volume tests. These changes are designed to better reflect the costs and professional input required for various pathology services, and have been developed with input from relevant peak pathology bodies. The Regulations do not specify any particular conditions that must be met before they can be exercised, and they extend the application of the Act by modifying the Pathology Services Table as prescribed under Section 4A of the Health Insurance Act 1973. The Regulations themselves do not provide for any exclusions, exemptions, or thresholds beyond what is already specified in the Act. The Regulations are a legislative instrument for the purposes of the Legislative Instruments Act 2003, and they commence on 1 July 2009.

Key Provisions

The Health Insurance (Pathology Services Table) Amendment Regulations 2009 (No. 2) provide a comprehensive update to the fees associated with certain pathology services under the Health Insurance Act 1973 (the Act). Section 4A of the Act allows for the regulation to prescribe a table of pathology services that sets out items of pathology services, the amount of fees applicable to each item, and rules for the interpretation of the pathology services table. The Act mandates that Medicare benefits for medical services, including pathology services, are calculated by reference to these prescribed fees (section 9). This regulatory framework ensures that the fees are aligned with the professional and operational costs involved in providing pathology services. The Regulations impose specific obligations on the parties involved, particularly medical practitioners and pathology service providers. These parties must comply with the updated fees as set out in the amended Pathology Services Table, which now includes increased fees for certain high complexity pathology items in Group P5 - Tissue Pathology (items such as 72830, 72836, 72838, 72846, 72847, 72848, 72849, and 72850). The amendments also clarify the conditions for claiming specific items, ensuring that the services provided are accurately billed and reimbursed according to the new fee structure. For instance, items 73059, 73060, 73061, 73064, and 73065 now allow for examinations that include material obtained by fine needle aspiration, provided an employee of the Approved Pathology Practitioner attends the aspiration. Failure to comply with the provisions of these Regulations may result in various consequences. Under the Health Insurance Act 1973, there are penalties for fraudulent claims or misrepresentations concerning pathology services. Such breaches may lead to civil or criminal penalties, with the latter potentially resulting in substantial fines and imprisonment. The specific penalties for breaches are not detailed in the explanatory statement, but they are in line with the general provisions of the Act and related legislative instruments, which can impose fines and penalties up to significant monetary amounts, as well as custodial sentences for serious offences. It is imperative for all stakeholders to adhere to the updated fees and conditions to avoid any legal repercussions.

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