§ 1126.52. Payment criteria.
(a) The Department will establish maximum reimbursement fees for same day surgical services based on the criteria established in § 1150.62 (relating to payment levels.)
(1) The level of reimbursement will be consistent with efficiency, economy and quality of care.
(2) The level of reimbursement will be sufficient to assure availability of services.
(b) The Department developed the fees as follows:
(1) Using paid claims history for services provided between July 1, 1985 and June 30, 1986, the Department identified claims for same day admissions and discharges.
(2) The cost for each claim was calculated by applying the hospital’s cost to charge ratios, as reported on its cost report for Fiscal Year 1984-1985.
(3) The Statewide average cost of each procedure was determined by first totaling the costs for all cases of a specific procedure. Each total was divided by the number of occurrences for that procedure.
(4) The fee for the ASC/SPU support component was determined by increasing the Statewide average cost of each procedure to account for inflation between the fiscal year represented by the data base and the fiscal year of implementation. The inflation factors used were 4.7% for Fiscal Year 1985-86, and 1.95% for Fiscal Year 1986-87.
(5) New procedures may be added to the ASC/SPU established list of procedures and fees after a sufficient number of occurrences are recorded in the Department’s files and enough data are obtained to establish a fee. Changes made in the list are subject to review by the Department’s professional medical staff and the recommendations of the Department’s medical and hospital subcommittees.
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