Commonwealth Numbered Regulations - Explanatory Statements

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HEALTH INSURANCE (PATHOLOGY SERVICES) REGULATIONS (AMENDMENT) 1996 NO.236

STATUTORY RULES 1996 No. 236

Issued by authority of the Minister for Health and Family Services

Health Insurance Act 1973

Health Insurance (Pathology Services) 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 and for certain professional services rendered by dental practitioners and optometrists.

Subsection 16A(3) of the Act provides that a Medicare benefit is not payable in respect of a pathology service that has been rendered by or on behalf of an approved pathology practitioner unless the service was rendered pursuant to a request made to the approved pathology practitioner by the treating practitioner or another approved pathology practitioner to whom the treating practitioner has made a request for that service.

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

The Health Insurance (Pathology Services) Regulations prescribe the particulars which must be included in requests for pathology services where the request is made pursuant to subsection 16A(3) of the Act.

The Regulations amend the Health Insurance (Pathology Services) Regulations as a result of the Government's 1996-97 Budget commitments. Requesting practitioners will be required to indicate on requests for pathology services whether those services, are in their opinion hospital -related services. The information provided will be aggregated at the State and Territory level to better assess the appropriate level of funding to hospitals in the States and Territories.

Identifying these services will not affect the payment of Medicare benefits.

The Regulations amend the Health Insurance (Pathology Services) Regulations by requiring additional particulars be included in requests for pathology services.

Paragraph 4(6)(d) provides that where a requesting practitioner forms an opinion that the requested pathology service is a hospital-related service, within the meaning of subregulation 4(6A) the request should include the letter "A".

Subregulation 4(6A) defines a pathology service which is a "hospital-related service" as:

(a)       a pathology service requested in relation to a person for a condition in relation to which the person will, or is likely to, receive treatment in a hospital or day hospital facility within 4 weeks of the service being provided; or

(b)       a pathology service requested in relation to a person for a condition in relation to which the person had received treatment in a hospital or day hospital facility in the 4 weeks immediately before provision of the service; or

(c)       a pathology service requested in relation to a person, the request for which is made in connection with a condition in relation to which, immediately before receiving the service resulting in the making of the request, the person had presented for treatment to a recognised hospital and was referred or directed to the practitioner who provided that service; or

(d)       a pathology service requested in connection with the provision of a professional service at a recognised hospital in relation to a person who is not admitted to that hospital in connection with that service.

Subregulation 4(6B) sets out the criteria a practitioner should have regard to when reaching an opinion as to whether a pathology service is a such a hospital-related service, namely, the nature of the pathology service and all the circumstances in which the service was provided, including, but not limited to:

(a)       the results of any examination of the person by the practitioner; and

(b)       the results of any tests in relation to the person conducted by, or made available to, the practitioner; and

(c)       the history, or any other information, given to the practitioner by the person; and

(d)       any letter, form or document given to the practitioner in connection with the provision by the practitioner of the service.

The Regulations will commence on 1 November 1996.