Decree No. 425 / 2011 Coll.
Decree on the determination of the value of the point, the amount of health care payments paid from public health insurance and the regulatory limitation of the amount of healthcare provided by public health insurance for 2012
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23.12.2011
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425
DECLARATION
of 15 December 2011
on the determination of the value of the point, the amount of health care payments paid on public health insurance and the regulatory limits on the volume of healthcare provided on public health insurance for 2012
The Ministry of Health provides pursuant to Article 17 (6) of Act No. 48 / 1997 Coll., on Public Health Insurance and on the amendment and addition of certain related laws, as amended by Act No. 117 / 2006 Coll., Act No. 245 / 2006 Coll., Act No. 261 / 2007 Coll. and Act No. 298 / 2011 Coll.:
This decree sets out for 2012 the values of the point, the amount of the health care payments provided to insured persons under Section 2 (1) of the Act No. 48 / 1997 Coll., on public health insurance and on the amendment and addition of certain related laws, as amended ("the Act '), as well as health care provided to insured persons from other Member States of the European Union, the European Economic Area and Switzerland under the directly applicable European Union1) and to insured persons of other States with whom the Czech Republic has concluded international social security agreements covering health care (" foreign insurance'), covered by public health insurance and regulatory restrictions on the volume of such health care in respect for the arrangements referred to in Sections 3 to 17, provided by:
(a) in contractual health care institutions, including professional medical institutions, treatment of long-term patients, medical establishments reporting treatment day No 00005 under the Decree issuing a list of health performance with point values (3) (hereinafter referred to as "the list of performance"), and hospital-type medical facilities pursuant to § 22a of the Act;
(b) contractual practitioners and practitioners for children and adolescents,
(c) in contractual outpatient medical institutions providing specialised outpatient health care, including outpatient medical institutions providing haemodialysis and orthoptic health care;
(d) in contract outpatient health care establishments providing health care in expertise 603 and 604 according to the performance list;
(e) contractual dental practitioners,
(f) in the contract outpatient health care establishments providing health care in expertise 222, 801, 802, 804, 805, 807, 809, 812 to 819, 822 and 823 according to the performance list (hereinafter referred to as "the listed expertise"),
(g) in the contract outpatient health care establishments providing medical care in the 911, 914, 916, 921 and 925, according to the performance list;
(h) in contract outpatient health care establishments providing medical care in a professional capacity 902 according to the performance list;
(i) medical emergency care facilities, medical emergency services and emergency medical services;
(j) contractual health care and rehabilitation facilities;
(k) in the framework of urgent health care in non-contractual medical establishments.
(1) The reference period refers to the year 2010 for the purposes of Annexes 1, 4 and 8 to this Decision and to Annexes 3, 5, 6 and 7 to this Decision.
(2) The evaluation period is the year 2012 for the purposes of Annexes 1, 4 and 8 to this Decision and for the purposes of Annexes 3, 5, 6 and 7 to this Decision.
(3) For the purposes of this decree, a unique insurer shall mean one insurer of the relevant health insurance undertaking treated by a medical institution in a given professional capacity at least once during the period of assessment or reference period, and shall not be determined whether the treatment is self-care or requested. If the insured person has been treated more than once by the medical institution within the relevant assessment period or reference period, the number of individual insured persons of the relevant health insurance undertaking treated in that professional shall only be included once. In the event of a merger of health insurance undertakings, the number of unique insured persons shall be the sum of the unique insured persons of health insurance undertakings which have merged. If the insured person has been insured by more than one health insurance company during the reference period, the number of individual insured persons shall be included only once.
(4) In calculating the total number of health establishments declared and the health insurance undertaking recognised as performing for the reference period referred to in Annexes 3, 5 to 8 to this Regulation, those points shall be understood as those points converted according to the list of performance as effective on 1 January 2012.
For healthcare provided to foreign insurers paid under the performance list, the value of the point in Sections 8, 12 and 14 and Annexes 1 to 8 to this Decree shall be determined.
(1) For health care provided by health care institutions, with the exception of health care provided in professional medical institutions, long-term sick hospitals, in health care institutions reporting on day 00005 according to the list of performance and in hospital-type health institutions, the value of the point, the amount of medical care payments and the regulatory limit are set out in Annexes 1, 9 to 11 to this Decree.
(2) For healthcare provided in professional medical institutions, long-term sick hospitals, in medical institutions reporting on treatment day 00005 according to the list of performance and in hospital-type health institutions, paid at a flat rate per day of hospitalisation or in accordance with the list of benefits, the value of the point, the amount of health care payments and the regulatory limit shall be as set out in Annex 1 to this Decree.
For health care provided by general practitioners and general practitioners for children and young people, paid by a combined capital charge, a combined capital charge with a top-up charge, or according to the list of benefits, the value of the point, the amount of health care payments and the regulatory limit shall be as set out in Annex 2 to this Decree.
For specialised outpatient health care provided in outpatient health institutions covered by the performance list, the value of the point, the amount of health care payments and the regulatory limit shall be as set out in Annex 3 to this Decree.
For outpatient health care provided in outpatient health care establishments in expert areas 603 and 604 according to the performance list, the value of the point, the amount of health care payments and the regulatory limitation shall be as set out in Annex 4 to this Decree.
(1) For dental care, the value of the point is CZK 0.95.
(2) The amount of health care payments in Czech crowns provided by dental practitioners not covered by paragraph 1 and the relevant regulatory restrictions are set out in Annex 12 to this Decree.
(3) The health insurance undertaking shall be entitled to limit the amount of remuneration to medical establishments so that the total cost of health insurance for dental care provided by dental practitioners in 2012 does not exceed the total amount of these costs set out in the health insurance plan of the health insurance undertaking. If the excess of the total amount of the health care payment provided by dental practitioners provided for in the health insurance plan of the health insurance undertaking for this health care would be due to the provision of more necessary and urgent health care compared to 2010, the health insurance company would take this greater amount into account in the remuneration.
For health care provided by outpatient health institutions in the listed expertise covered by the performance list, the value of the point and the amount of the health care payments shall be set out in Annex 5 to this Decree.
For medical care provided by outpatient medical institutions in the field of expertise 911, 914, 916, 921 and 925 according to the performance list, the value of the point and the amount of medical care payments shall be as set out in Annex 6 to this Decree.
For health care provided by outpatient medical institutions in the field of competence 902 according to the performance list, the value of the point and the amount of the health care payments shall be as set out in Annex 7 to this Decree.
For health care provided under the medical rescue service paid according to the performance list, the value of the point is set at CZK 1.10.
For the performance provided by the transport health service covered by the performance list, the value of the point and the amount of the health care payments shall be as set out in Annex 8 to this Decree.
For medical care provided under the medical first aid service paid according to the performance list, the value of the point is set at CZK 0.95.
(1) For comprehensive spa care provided by health care facilities, the payment for one day's stay is set at the amount agreed on 31 December 2010, but at least CZK 850.
(2) For the benefit of spa care provided by health care facilities, the payment for one day's stay is set at the amount agreed on 31 December 2010, but at least CZK 280.
(3) For health care provided in health care centres, the payment for one day's stay is fixed at the amount agreed on 31 December 2010, but at least CZK 540.
According to § 3 to 15, the procedure is to be followed unless the health insurance company and health care establishment agree otherwise, subject to the conditions laid down in § 17 (6) of the Act.
For urgent medical care in non-contractual medical establishments, paid according to the performance list, the point value shall be 85% of the point value set out in Sections 8, 12 and 14 and Annexes 1 to 8 to this Decree. The resulting point value is rounded to 2 decimal places.
This Decree shall take effect on 1 January 2012.
Minister:
Doc. MUDr. Heger, CSc., v. r.
Příloha č. 1
Annex No. 1 to Decree No. 425 / 2011 Coll.
Value of the point, amount of health care payments and regulatory restrictions under § 4
A) Constitutional care pursuant to § 4 (1)
1. The remuneration to the healthcare establishment in 2012 includes the individually contracted remuneration component, the case flat-rate payment, the remuneration allocated to the case flat-rate payment and the outpatient remuneration component. All healthcare provided in 2010, medical establishments declared by 31 May 2011 and health insurance companies recognised by 30 September 2011 are included in the reference period. All healthcare provided in 2012, medical establishments declared by 31 March 2013 and health insurance companies recognised by 30 May 2013 are included in the evaluation period.
2. Individual contractually agreed payment component
2.1. The level and method of payment of healthcare classified according to the Classification of hospitalised patients (4) (hereinafter referred to as "Classification") into groups related to diagnosis:
(a) 08021, 08022, 08023, 08041, 08042, 08043, 08181, 08182, 08183,
(b) 05011, 05012, 05013, 05070, 05161, 05162, 05163, 05111, 05112, 05113,
(c) 02041, 02042, 02043,
(d) 01051, 01052, 01053,
(e) 05191, 05192, 05193,
(f) 06061, 06062, 06063,
(g) 07041, 07042, 07043,
(h) 08191, 08192, 08193,
(i) 13091, 13092, 13093,
as referred to in Annex No 9 (hereinafter referred to as "the listed groups'), the health insurance undertaking shall agree with the healthcare establishment by contract. If the health insurance company agrees with the health care establishment, the contractually agreed remuneration component may include the payment of healthcare other than that referred to in the first sentence; in that case, this remuneration, as well as the remuneration for health care classified under Clarification4), shall not be included in the remuneration referred to in point 3.
2.2 The amount of the reimbursement of medicinal products and food for special medical purposes (hereinafter referred to as the "medicinal product"), marked "S" in accordance with Paragraph 39 (1) of Decree No. 376 / 2011 Coll., implementing certain provisions of the Public Health Insurance Act (hereinafter referred to as the "Order"), per individual insured person to whom that medicinal product has been provided during the evaluation period, is set at 98% of the average remuneration per individual insured person for the reference period related to each diagnosis. The total remuneration related to the individual diagnosis shall be calculated by multiplying the remuneration per individual insured person determined according to the first sentence and the number of individual insured persons to whom that medicinal product has been provided in the diagnosis during the evaluation period. The highest possible total remuneration for the period under assessment shall be calculated as a multiple of the remuneration determined according to the first sentence and 110% of the number of individual insured persons who received the above medicinal product during the reference period in the diagnosis.
3. Reimbursement by case flat rate
3.1 The flat-rate payment (Pudrg2012) shall include the remuneration for health care classified under the Classification in the groups related to the diagnosis listed in Annex 10 to this Decree and shall be as follows:
Pudrg2012 = CMred * ZS2012
where:
CMred reduced amount of CMfa2012 to be determined according to the following conditions:
(a) if the ratio of CMalfa2012 / CMalfa2010 is greater than 1,05 and PPalfatrg is greater than 1,03, then
CMred = CMMalfa2010 * 1,05
where:
CMalfa2012 Number of hospitalisation cases reported by medical institutions and by health insurance undertakings recognised in the assessment period classified under the Classification in groups related to diagnosis, multiplied by the indices of those groups listed in Annex 10 to this Decree
CMalfa2010 Number of hospitalisation cases completed and by health insurance undertakings recognised in the reference period which are classified under the Classification in groups related to diagnosis, multiplied by the indices of those groups listed in Annex 10 to this Decree
PPalfadrg ratio of the number of health establishments declared and of health insurance undertakings recognised by hospitalisation, completed in 2012, included in groups related to diagnosis according to the Classification, listed in Annex 10 to this Decree, and health institutions declared and health insurance companies recognised by the number of hospitalisation, completed in 2010, included in groups related to diagnosis according to the Classification, listed in Annex 10 to this Decree
(b) where the ratio of CMalfa2012 / CMalfa2010 is less than or equal to 1,05, and at the same time the ratio of CMalfa2012 / CMalfa2010 is not greater than (PPalfatrg + 0,02),
CMred = CMalfa2012
(c) where the conditions laid down in (a) or (b) are not met and where the ratio of CMalfa2012 / CMalfa2010 is higher than (PPalfatrg + 0,02),
CMred is reduced by the number of percentage points that make up the difference between CMalfa2012 / CMalfa2010 and (PPalfatrg + 0,02) under the following conditions:
1) if CMalfa2012 / CMalfa2010 is less than or equal to 1,05, then
CMred = CMalfa2012
2) if CMalfa2012 / CMalfa2010 is greater than 1,05, then
CMred = CMMalfa2010 * 1,05
ZS2012 standard rate for flat rate settlement, calculated as follows:
ZS2012 = [IZS2010 * (1 - Kp) + (ZSref * Kp)] * Kn
where:
The reference individual base rate shall be calculated as follows:
IZS2010 = Uall2010 / CMall2010
where:
Uall2010 Total amount of remuneration for medical establishments declared and recognised care provided by the health insurance company during hospitalisation during the reference period, including settlement of regulatory restrictions and payments made, excluding payment for outpatient remuneration
CMall2010 Number of hospitalisation cases completed in the reference period classified under the Classification as diagnostic groups multiplied by the indices of those groups listed in Annexes 9, 10 and 11 to this Decree
Kp approach coefficient to be determined at 0,25
ZSref reference (national) standard rate, which is set at CZK 29 500
Kn coefficient of increase of basic rate of ZS2012, which is set at 1,07
4. Reimbursement in the form of a flat rate payment
4.1 The remuneration to be paid in the form of a flat-rate payment shall include the remuneration for health care classified under the Classification in the groups related to the diagnosis listed in Annex 11 to this Decree. For the reimbursement of the flat-rate compensation paid on the basis of the performance list, the medical establishments declared and the health insurance undertaking recognised for the period under assessment, the value of the point of ICBref * 1,07 up to the limit (LIM PUbetadrg2012) calculated as follows:
LIM PUbetadrg2012 = [(Vbeta-Drg2010 * ICBref) + ZUMbeta-Drg2010 + ZULPbeta-Drg2010 + LPbeta-Drg2010 + KPbeta-Drg2010] * 1,07
where:
Vbetadrg2010 the total number of health establishments declared and recognised by the health insurance company as performing during hospitalisation for a reference period classified under the Classification in the groups listed in Annex 11 to this Decree. The numbers of points according to the first sentence shall be converted according to the performance list as effective on 1 January 2012.
ICBref calculated individual price of the point of the medical facility, which is determined as the proportion of Uref / Bref
where:
Uref total remuneration due to the medical establishment for all health care provided in the reference period, after settlement of all regulatory measures, except for the regulation on prescribed medicinal products and medical devices, reduced by remuneration for the medicinal products specifically charged and the material specifically charged, provided in the reference period, recognised and recognised by the health insurance company in connection with patient care, by a lump sum to be paid for medicinal products under Section 17 (7) of the Act, and by other health care paid in Czech crowns (KPref)
Bref total number of health establishments declared and by health insurance undertakings recognised points, translated according to the performance list as effective on 1 January 2012, for health care provided during the reference period
ZUMbetadrg2010 Total amount of remuneration for medical establishments declared and recognised by a health insurance undertaking, separately charged material provided in respect of performance during the reference period during hospitalisation during the reference period, classified under the Classification in the groups listed in Annex 11 to this Decree.
ZULPbetadrg2010 Total amount of remuneration for medical establishments declared and recognised by the health insurance company for the medicinal products specifically charged in respect of performance during the reference period during hospitalisation during the reference period classified under the Classification in the groups listed in Annex 11 to this Decree.
LPbetridrg2010 flat-rate amount to be paid for medicinal products pursuant to Article 17 (7) of the Act on the treatment dates declared and by a health insurance undertaking recognised as a reference period related to hospitalisation during the reference period classified under the Classification in the groups listed in Annex 11 to this Decree.
KPbeta Drg2010 Total amount of remuneration for other health care paid in Czech crowns declared and by a health insurance company recognised as a reference period provided to the healthcare institution during hospitalisation during the reference period, which are classified under the Classification in the groups listed in Annex 11 to this Decree.
4.2 For the reimbursement of the flat-rate compensation paid on the basis of the performance list, the health insurance company declared and recognised by the health insurance company for the period considered above the calculated limit (LIM PUbetadrg2012), the value of the point (ICBref * 1,07) * 0,5 and the amount of the remuneration for the separately charged material, the medicinal products specifically charged, shall be calculated as follows:
(ZUMbetadrg2012 + ZULPbetadrg2012 + LPbetadrg2012 + KPbetadrg2012) * 0,5
where:
ZUMbetadrg2012 Total amount of remuneration for medical establishments declared and recognised by the health insurance company separately charged material provided in respect of performance during the evaluation period during hospitalisation during the evaluation period, classified under the Classification in the groups listed in Annex 11 to this Decree.
ZULPbetadrg2012 Total amount of remuneration for medical establishments declared and recognised by the health insurance company for medicinal products specifically charged in connection with performance during the evaluation period during hospitalisation during the evaluation period which are classified under the Classification in the groups listed in Annex 11 to this Decree.
LPbetridrg2012 a flat-rate amount to be paid for medicinal products pursuant to Article 17 (7) of the Act on the treatment dates declared and by a health insurance undertaking recognised for the period of assessment related to hospitalisation during the evaluation period which are classified under the Classification in the groups listed in Annex 11 to this Decree.
KPbetridrg2012 Total amount of remuneration for other health care paid in Czech crowns declared and by a health insurance company recognised as having been evaluated during the period provided by the medical institution during hospitalisation during the evaluation period which are classified under the Classification in the groups listed in Annex 11 to this Decree.
up to the total amount of the remuneration (MAX PUbetadrg2012) calculated as follows:
MAX Pupatedrg2012 = LIM Pupatadrg2012 * 1,03
5. For health care paid according to the list of performances, including health care provided to foreign insured persons, the value of the point is set at CZK 0.90.
6. The umbilical component of the remuneration includes the reimbursement of specialised outpatient health care, medical care in the fields of expertise 603 and 604, according to the list of performance, medical care provided by general practitioners for adults and practitioners for children and adolescents, dental care provided by dental practitioners, medical care in the listed professions, medical transport, first aid and medical care provided in the fields of expertise 902, 911, 914, 921 and 925 (hereinafter referred to as "outpatient care '), with the exception of those shown in income and discharge examinations.
6.1. For specialised outpatient health care, paid according to the list of performances, the value of the point and the amount of medical payments shall be as set out in Annex 3 to this Decree.
6.2. For healthcare provided by professionals 603 and 604, according to the performance list, paid in accordance with the performance list, the value of the point and the amount of health care payments shall be set out in Annex 4 to this Decree.
6.3. For health care provided by general practitioners and practitioners for children and adolescents, paid by a combined capitalisation payment, a combined capitalisation payment with a top-up of the cap or according to the list of benefits, the value of the point and the amount of the health care payments shall be set out in Annex 2 to this Decree.
6.4. Health care provided by dental practitioners is paid in accordance with Section 8 of this Decree.
6.5. For healthcare provided in the listed expertise, paid according to the performance list, the value of the point and the amount of the health care payments shall be set out in Annex 5 to this Decree.
6.6. For the performance of health transport, paid according to the list of services, the value of the point and the amount of the health care payments shall be as set out in Annex 8 to this Decree.
6.7. The medical care provided under the first-aid medical services shall be reimbursed in accordance with Section 14 of this Order.
6.8. For healthcare provided in a professional capacity 902, according to the performance list, paid according to the performance list, the value of the point and the amount of the health care payments shall be set out in Annex 7 to this Decree.
6.9. For medical care provided by professionals 911, 914, 921 and 925, according to the performance list, paid according to the performance list, the value of the point and the amount of health care payments shall be as set out in Annex 6 to this Decree.
6.10. If the sum of the payments calculated in accordance with points 6.1 to 6.9 is less than 98% of the compensation for outpatient care provided in the reference period (Uamb2010), the medical institutions declared and the health insurance company recognised the number of points for outpatient care provided in the assessment period will be at least 100% of the outpatient care provided in the reference period, and if, in the evaluation period, the health care establishment has treated at least 100% of the individual insured persons compared to the reference period, then the resulting payment for outpatient care provided in the evaluation period (UVamb2012) shall be set at:
UVamb2012 = Uamb2010 × 0,98
6.11. If the medical establishment declared and recognised by the health insurance undertaking for outpatient care performance provided in the assessment period is less than 100% of the number of outpatient care outcomes provided in the reference period, and at the same time if less than 100% of the unique insured persons are treated in the assessment period compared to the reference period, then UVamb2012 will be reduced by the same number of percentage points by which 100% of the value set out in point 6.10 has not been reached. For the reduction specified in the first sentence, the higher of the values by which 100% of the value specified in paragraph 6.10 has not been reached shall be used.
6.12. For the contracted power 09563, according to the list of performance, the value of the point of CZK 0,91 is determined and for the contracted power 88101, according to the list of performances the value of the point of CZK 1 is determined.
7. If changes occur in the scope and structure of the care provided compared to the reference period and the health insurance company agrees to these changes, they shall be taken into account in the contract, including quantification of the effects on payments.
8. In the event that the health care facility provides 50 or less health care to the insured persons of the relevant health insurance company during the reference period, such health care shall be paid according to the list of performances with a value of CZK 0.90.
9. The health insurance company may grant a monthly advance payment of one twelfth of the amount of the remuneration provided for under this Decree from the data for the reference period to the health institution. In determining the amount of the advance payment, the health insurance undertaking shall take into account changes in the scope and structure of the care provided, including changes in the number of hospitalizations, the number of points and the number of unique insured persons. The interim remuneration for the evaluation period shall be settled financially in the context of total financial settlement, including regulatory restrictions, no later than 180 days after the end of the evaluation period.
B) Constitutional care under § 4 (2)
1. Rate per day hospitalisation
(a) The flat rate per day of hospitalisation shall be determined for each patient category and type of treatment day separately and shall include the value of the relevant treatment day, including the direction assigned to the treatment day and patient category according to the performance list, the flat-rate amount to be paid for the medicinal products referred to in Article 17 (7) of the Act and the medical performance to be reported as income and discharge tests according to the performance list.
(b) The flat rate for one day of hospitalisation in the evaluation period shall be 103% of the flat rate for one day of hospitalisation belonging to the healthcare establishment in the reference period.
(c) Where there are changes in the scope and structure of the covered care provided in a health institution compared to the reference period and the health insurance company agrees to those changes, it shall take them into account in the draft contract, including quantification of the effects on the remuneration.
2. Reimbursement of outpatient care, special outpatient care and special constitutional care
a) For outpatient care paid according to the performance list, the value of the point is CZK 0.95.
b) For special outpatient care provided under § 22 (c) of the Act, paid according to the list of performances, the value of the point of CZK 0,90 shall be set at 100% of the volume calculated as follows:
PBRO × POPOPOPOPro,
where:
PBRo total number of health establishments declared and health insurance undertakings recognised by the points recognised for the reference period
POPho number of unique insured persons treated with medical devices during the evaluation period
POPro Number of individual insured persons treated by health care institutions in the relevant professional capacity in the reference period
Health care provided to medical institutions over 100% of the calculated volume is paid with a value of CZK 0.40. Financial settlement shall be made no later than 120 days after the date of the end of the evaluation period.
c) For special institutional care provided in hospital-type medical institutions under § 22a of the Act, paid according to the list of performances, the value of the point of 0.90 CZK is determined.
(C) Regulatory restrictions
1. Regulatory limitation of the flat-rate payment
1.1. If a health insurance undertaking finds derogations in the classicaci4) in a specific health establishment within the meaning of special-purpose encoding, it shall conduct targeted or random enquiries which confirm or disprove suspected special-purpose behaviour or encoding.
1.2. Targeted investigations are the search for specific hospitalisation cases that showed significant deviations in the analysis using the information system. For these cases, the health insurance company will require complete clinical documentation and the review doctors will carry out a clinical audit. If the result of a clinical audit is to establish that a medical institution has failed to comply with the reporting methodology rules and for encoding and the hospitalisation case has therefore been misclassified into the higher relative weight DRG group, the health insurance undertaking shall reduce the remuneration accordingly to the following amount:
Mathematical expression:
(CMoriginal - CMrevised) × ZS2012 × 3
where:
CMOriginal number of hospitalisation cases completed in the evaluation period, which are classified according to Classication4) in groups related to diagnosis, multiplied by the indices of these groups listed in Annexes 9, 10 and 11 to this Regulation, reported by the health care institution before conducting targeted or random investigations by the health insurance undertaking
CMrevised number of hospitalisation cases completed in the evaluation period, classified under the Classification (4) in groups related to diagnosis, multiplied by the indices of these groups listed in Annexes 9, 10 and 11 to this Regulation, by medical establishments declared and by a health insurance undertaking recognised by a targeted or random investigation
1.3. Accidental investigation means the random selection of a specified number of hospitalisation cases in the relevant DRG basis for which a clinical audit will be carried out, i.e. a comparison of reported care with healthcare, as recorded in the clinical documentation. If irregularities are detected, the health insurance company shall apply this finding as a regulatory measure for the entire DRG basis over the period considered and reduce the remuneration.
Mathematical expression:
(a) revisions in a statistically less significant number of cases of the relevant DRG base:
((CMoriginal - CMrevised) / (CMoriginal)) x ITEM CM baze x ZS2012 _ x 0,2
(b) revisions in a statistically significant number of DRG cases of relevant baze:
((CMoriginal - CMrevised) / (CMoriginal)) × ITEM CM baze × ZS2012 × 0,8
where:
CM baze sum of relative weights given by DRG baze
DRG base of the aggregated group from groups related to diagnosis according to Classication4). They are given by the first 4 characters of the five-digit code of the DRG group.
Statistical significant number of cases of relevant DRG baze
more than 5% of cases but at least 30 cases within the relevant DRG baze in the relevant health care facility
Statistics of less significant cases of the relevant DRG baze
less than 5% of cases but at least 10 cases within the relevant DRG baze in the relevant health care facility
2. Regulatory restrictions on prescribed medicinal products and medical devices
(a) Where the total remuneration for medicinal products and medical devices prescribed by medical devices to insured persons by the relevant health insurance undertaking during the evaluation period, with the exception of medicinal products or medical devices approved by the medical practitioner, exceeds 98% of the remuneration for medicinal products and medical devices prescribed in the reference period, with the exception of medicinal products or medical devices authorised by the medical practitioner, the health insurance undertaking shall reduce the total remuneration for the medical establishment by a maximum of 40% of that excess. The reduction according to the sentence of the first health insurance undertaking shall not apply if the health care institution demonstrates that the increased total remuneration for prescribed medicinal products and medical devices has been caused by a change in the amount or manner of their reimbursement, possibly due to changes in the structure of the insured persons of the health insurance undertaking concerned.
(b) In the event that a healthcare institution has provided healthcare to the relevant health insurance undertaking 50 or less insured persons during the assessment period, the health insurance undertaking shall not apply the regulation referred to in point 1.
Příloha č. 2
Annex No 2 to Decree No 425 / 2011 Coll.
Value of the point, amount of health care payments and regulatory restrictions pursuant to § 5
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Regulation Information
| Citation | Decree No. 425 / 2011 Coll., on determining the value of the point, the amount of health care payments paid from public health insurance and the regulatory limitation of the volume of healthcare provided by public health insurance for 2012 |
|---|---|
| Regulation Type | Order |
| Author | - |
| Collection | Code of Laws |
| Date of Promulgation | 23.12.2011 |
|---|---|
| Effective from | 01.01.2012 |
| Effective until | - |
| Status | Valid |
The regulation text is for informational purposes only.
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