Commonwealth Numbered Regulations - Explanatory Statements

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HEALTH INSURANCE (1996-97 DIAGNOSTIC IMAGING SERVICES TABLE) REGULATIONS(AMENDMENT) 1996 NO. 337

EXPLANATORY STATEMENT

STATUTORY RULES 1996 No. 337

Issued by the authority of the Minister for Health and Family Services

Health Insurance Act 1973

Health Insurance (1996-97 Diagnostic Imaging Services Table) Regulations (Amendment)

The Health Insurance Act 1973 ("the Act") provides, in part, for the payment of Medicare benefits for professional services rendered by medical practitioners, dental practitioners and optometrists.

Section 133 of the Act provides that the Governor-General may make regulations for the purposes of the Act.

Section 4AA of the Act provides that regulations may prescribe a table of diagnostic imaging services ("the table") and the Health Insurance (1996-97 Diagnostic Imaging Services Table) Regulations prescribe such a table.

Section 4AB of the Act provides that a regulation under section 4AA may provide for a reduction in the fee applicable to a diagnostic imaging service where that service and at least one other medical service, which may be a service other than a diagnostic imaging service, are provided to the same patient.

Section 23DX of the Act provides for the grant to a medical practitioner of a remote area exemption. The exemption exempts a medical practitioner from the requirements that Medicare benefits are not payable for an R-type service unless there was a request in writing for the service from another medical practitioner (subsection 16B(7)).

An R-type service is a service in the diagnostic imaging services table identified with the symbol (R) and comprises the majority of services in the table. Medicare benefits are not payable for an R-type service unless that service was requested in writing by another medical practitioner or where an exemption from the requesting requirement applies.

The Regulations implement the 1996-97 Budget initiative in accordance with section 4AB of the Act to introduce multiple services rules for diagnostic imaging services by amending the Health Insurance (1996-97 Diagnostic Imaging Services Table) Regulations. The amendments insert a new rule of interpretation (Rule 15) in the table. Rule 15 provides for a reduction in the fees for diagnostic imaging services where multiple services are rendered by a medical practitioner for the same patient on the same day. The Regulations also amend certain items in the table amending various medical services eg; providing that certain services maybe rendered to adults as well as to children (regulation 4).

Details of the Regulations are set out in the attachment.

The Regulations come into effect from 20 January 1997.

Attachment

DETAILS OF THE HEALTH INSURANCE (1996-97 DIAGNOSTIC IMAGING SERVICES TABLE) REGULATIONS (AMENDMENT)

Regulation 1 provides for the Regulations to commence on 20 January 1997.

Regulation 2 amends the Health Insurance (1996-97 Diagnostic Imaging Services Table) Regulations as set out in these Regulations.

Rules of Interpretation

Regulation 3 adds Rule 15 to the Rules of Interpretation. This Rule implements the 199697 Budget initiative to implement multiple services rules for diagnostic imagine, services.

Subrule 15(1) provides that if a medical practitioner renders 2 or more diagnostic imaging services for the same patient on the same day, the fee for the service, other than the item with the highest fee, is reduced by $5.00.

Subrule 15(2) provides that if a medical practitioner renders at least one R-type diagnostic imaging service and at least one consultation for the same patient on the same day, the fee for the diagnostic imaging service with the highest fee is reduced by the least of: $35.00 where the consultation has a fee equal to or greater than $40.00, or $15.00 if the fee for the consultation is less than $40.00, or the amount of the fee for the diagnostic imaging service. This latter provision will ensure that the reduction in the fee for the diagnostic imaging service with the highest fee does not exceed the amount of the reduction.

For example, a medical practitioner renders to a patient on the same day a consultation with a fee of $62.85 together with at least one R-type diagnostic imaging service. If the fee for the diagnostic imaging service with the highest fee was $34.05, the reduction would have been $35.00 except for the provision that the reduction shall not exceed the fee for that service. In this case, the reduction applied to the relevant diagnostic imaging service will be $34.05 rather than the $35.00.

Subrule 15(3) provides that subrule 15(2) only applies to the consultation which has the highest fee as set out in items that apply to consultations. The effect of this provision is to identify one consultation and that consultation is the consultation with the highest fee. The level of the fee for the consultation identified under this subrule will determine the amount of the reduction where subrule 15(2) applies.

Subrule 15(4) provides that if a medical practitioner renders at least one R-type diagnostic imaging service and at least one non-consultation service for the same patient on the same day, the fee for the diagnostic imaging service with the highest fee is reduced by $5.00.

Subrule 15(5) provides that the sum of fee reductions under subrules 15(2) and 15(4) is not to exceed the fee of the diagnostic imaging service to which the reductions apply. This provision recognises that where both subrules 15(2) and 15(4) apply, the reduction will be made to the same diagnostic imaging service with the highest fee and in circumstances where the fee for that item is less than the sum of the reductions, there would except for

Subrule 15(6) provides that Rule 15 does not apply to services rendered by medical practitioners exempted under the Remote Area Exemption under section 23DX of the Act.

Subrule 15(7) defines a "consultation" as a service under an item listed in Groups A1 to A9 of the general medical services table and a non-consultation service as a service under an item listed in the general medical services table other than in Groups A1 to A9.

Subrule 15(8) defines a reference to a "highest fee" as a reference to a fee for an item in the first claim processed by the Health Insurance Commission for which subrules 15(1), (2) or (4) applies. This provision applies where the services that are rendered by a medical practitioner for the same patient on the same day may be contained in two or more claims that may not be submitted for assessment to the Health Insurance Commission at the same time. The subsequent claim or claims may require a re-assessment of the previous claim or claims and adjustments to the benefits paid or payable. The provision enables the Commission to reduce the amount of reassessment procedures that would otherwise be involved.

Each of the subrules 15(1), 15(2) and 15(4) may apply to-diagnostic imaging services rendered by a medical practitioner for the same patient on the same day. For example, if two or more diagnostic imaging services are rendered, subrule 15(1) will apply. If one of the diagnostic imaging services was an R-type service and a consultation was also rendered, subrule 15(2) will also apply. If a non-consultation service was also rendered, subrule 15(4) would also apply. The application of the subrules is modified as provided elsewhere in the subrules where the sum of the reductions exceeds the fee for the service to which the reduction or reductions apply.

Services and Fees

Regulation 4 amends items in the table to clarify the intent of the items.

The amendment to item 58300 deletes the condition that the service relates only to a service where both the wrist and the knee is x-rayed so that either or both may be rendered.

The amendment to item 58939 provides that the service may be rendered to adults as well as to children.

The amendment to item 59751 provides that the service relates to a double contrast service.

The amendment to item 61462 provides that the fee for the repeat image comprises only the fee for the investigation and the repeat image rather than the fee for the investigation plus the fee for the investigation and the repeat image.


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