TRICARE REIMBURSEMENT RATES UPDATE 17 May 2008
Posted by Service Officer on May 17th, 2008
Every year, the federal government tweaks the elaborate system that determines the amount doctors get paid for care and procedures, known as “reimbursement rates”. Those changes, in turn, translate into changes in cost shares, or co-pays, for Tricare beneficiaries. Payment for inpatient hospital stays in specified locations outside the 50 United States and the District of Columbia, are made utilizing the lesser of (a) billed charges or (b) the prospectively determined per diems adjusted by a country specific index (CSI). The per diem rates are developed into reimbursement groupings by utilizing diagnosis codes as contained in the International Classification of Diseases, 9th Revision, and Clinical Modification (ICD-9-CM). The per diem rates are the maximum allowable amounts that Tricare shall reimburse and the amount on which patient cost-shares are calculated. The National U.S. per diem rate is multiplied by a unique CSI factor which adjusts the National U.S. per diems for the applicable country. The country specific hospital per diem, for those specified locations outside the 50 United States and the District of Columbia is the product of the National U.S. per diem and the CSI. This payment system applies to all hospitals providing hospital inpatient services and professional provider reimbursements in the Philippines, Panama, and other overseas areas as designated by the Government.
The CSI is a factor obtained from the World Bank’s International Comparison Program. The index factor is based on a large array of goods and services or market basket within the specific country which is then standardized and weighted to a U.S. standard and currency. The use of the CSI enables a conversion and therefore creates parity between the U.S. and the specific country in the purchasing of the same amount and type of medical services. Tricare is utilizing a two year phase in approach for the implementation of the World Bank’s International Comparison Program CSI. Per change 77 dated 7 APR 08 to the Tricare Reimbursement Manuel for the Philippines and Panama, the first year of the CSI phase in has been set at 0.52 and 0.70 through 28 FEB 08. The second year of the CSI phase in has been set at 0.229 for the Philippines and 0.60 for Panama effective 1 MAR 09. However, their is a requirement that all providers that submit bills to Tricare and are effected by the changes must be given at least 100 days notice so it is likely that the changes will not take effect until AUG 08 and AUG 09 respectively. The change equates to a 27.1point index reduction (52%) for the Philippines and a 10 point index reduction (15%) for Panama assuming nothing is done to reverse these reductions. For additional info refer to http://manuals.tricare.osd.mil. [Source: Tricare Reimbursement Manual 6010.55-M w/Change 77 Chap 1 Sect 34 & 35dtd 7 Apr 08 ++]
