Reference Based Pricing is not new, it’s been around for a long time. Did you know that Texas Workers Compensation is a Reference Based Pricing plan?
“The reimbursement calculation used for establishing the Maximum Allowable Reimbursement (MAR) shall be the Medicare facility specific amount, including outlier payment amounts, determined by applying the most recently adopted and effective Medicare Inpatient Prospective Payment System (IPPS) reimbursement formula and factors as published annually in the Federal Register. The following minimal modifications shall be applied.”
“The sum of the Medicare facility specific reimbursement amount and any applicable outlier payment amount shall be multiplied by:
- 143 percent; unless
- A facility or surgical implant provider requests separate reimbursement in accordance with subsection (g) of this section, in which case the facility specific reimbursement amount and any applicable outlier payment amount shall be multiplied by 108 percent.
- Implantables, when billed separately by the facility or a surgical implant provider in accordance with subsection (f)(1)(B) of this section, shall be reimbursed at the lesser of the manufacturer’s invoice amount or the net amount (exclusive of rebates and discounts) plus 10 percent or $1,000 per billed item add-on, whichever is less, but not to exceed $2,000 in add-on’s per admission.”
SOURCE: Subchapter E. Health Facility Fees
