Shandong Releases Pricing for 'Internet+' Medical Services, Boosting Reimbursement Prospects

VCBeat (WeChat ID: vcbeat) has learned that on November 20, the Shandong Provincial Healthcare Security Administration issued the “Implementation Opinions on Improving Pricing and Medical Insurance Reimbursement Policies for ‘Internet+’ Medical Services,” which established the criteria for including and excluding items from the pricing schedule for “Internet+” medical services and specified the prices for the first batch of such services.

The "Opinions" mainly include the following content:

1. Classified Management of Medical Service Price Items: Differentiated by Non-profit and For-profit Medical Institutions.

2. Excluded items: including but not limited to remote surgical guidance, remote ward rounds, medical consultation, education and training, research follow-up, data processing, medical appraisal, health consultation, health management, and convenience services.

3. Release the prices for the first batch of "Internet+" medical service items; public medical institutions shall charge fees not exceeding the maximum prices published by the Provincial Healthcare Security Administration.

4. Internet-based follow-up consultations provided by medical personnel of different levels shall all be charged at the price for general outpatient consultation services.

In accordance with the spirit of the Opinions of the General Office of the State Council on Promoting the Development of “Internet + Medical Health” (Guo Ban Fa [2018] No. 26), the Notice of the General Office of the People’s Government of Shandong Province on Issuing the Action Plan for Building Shandong Province as a Demonstration Province for Advancing “Internet + Medical Health” (2019–2020) (Lu Zheng Ban Fa [2019] No. 19), and the Guiding Opinions of the National Healthcare Security Administration on Improving Pricing and Medical Insurance Payment Policies for “Internet +” Medical Services (Yi Bao Fa [2019] No. 47), the following implementation opinions are hereby proposed to improve pricing and medical insurance payment policies for “Internet +” medical services.

(I) Classified Project Management. "Internet+" medical services conducted by non-profit medical institutions in accordance with laws and regulations shall be managed on a project-by-project basis; no charges may be levied on patients for medical service price items that have not been approved. For-profit medical institutions conducting "Internet+" medical services in accordance with laws and regulations may independently establish medical service price items. Internet hospitals shall apply the corresponding price item policies based on their registered ownership structure and operational nature.

(II) Authority for Project Establishment. Pricing items for “Internet+” medical services shall be established by the Provincial Healthcare Security Administration. For existing offline service items of medical institutions that are conducted or extended online and for which project establishment and fee charging are applied, the municipal healthcare security administrations shall accept the applications; those meeting the requirements shall be submitted to the Provincial Healthcare Security Administration for centralized review and approval. Applications for project establishment and fee charging submitted by provincial- or ministerial-level public medical institutions located in Jinan shall be directly reported to the Provincial Healthcare Security Administration.

When establishing medical service price items, the nationally unified principles for item establishment, item names, service connotations, pricing units, pricing descriptions, coding rules, and other relevant standards shall be strictly implemented.

(III) Conditions for Establishing Projects. To establish a pricing item for “Internet+” medical services, the following basic conditions must be met simultaneously: The service must be an “Internet+” modality permitted by the competent health administrative authorities, with clear clinical pathways and well-defined technical specifications; it must provide direct services to patients; the service process must be conducted remotely via the Internet or other media; the service must achieve the same functions as its offline counterpart; and the service must have a substantial effect on the diagnosis and treatment of diseases. It is prohibited to create new items by changing wording, fragmenting the scope of services, adding non-medical steps, or under any other pretenses.

(4)Items Not Included.Services that occur solely between medical institutions or between medical institutions and other entities, and are not directly provided to patients; services provided by medical institutions to patients that do not constitute diagnostic and treatment activities; and services provided by non-medical personnel shall not be included as items in the pricing of medical services. The aboveIncluding but not limited to remote surgical guidance, remote ward rounds, medical consultation, education and training, research follow-up, data processing, medical appraisal, health consultation, health management, and patient convenience services.

(1) The pricing of “Internet+” medical services is subject to provincial-level administration. Prices for “Internet+” medical services provided by public medical institutions are primarily regulated by the government. The Provincial Healthcare Security Administration shall establish and adjust the price ceilings for “Internet+” medical service items offered by public medical institutions across the province (see Appendix).The prices listed in the attachment represent the maximum prices for tertiary public medical institutions. The maximum prices for other public medical institutions shall be reduced by 10%–30% on this basis. Public medical institutions shall charge fees not exceeding the maximum prices published by the Provincial Healthcare Security Administration.

"Internet Plus" medical services provided by public medical institutions that primarily cater to personalized and high-level needs, as well as "Internet Plus" medical services delivered to countries or regions outside mainland China, shall comply with the requirements for controlling the scale of special-needs medical services and be subject to market-regulated pricing. Public medical institutions shall independently determine prices based on a comprehensive consideration of factors such as service costs and patient demand, and notify their local municipal healthcare security administration in writing. Provincial- or ministerial-level public medical institutions located in Jinan shall provide written notification to the Provincial Healthcare Security Administration.

Non-public medical institutions providing “Internet+” medical services shall implement market-regulated pricing.

(II) Price Management for Newly Introduced Services. Public medical institutions shall submit materials such as price proposals, cost estimation results, economic evaluation reports, and comparative analyses with similar offline services to the municipal healthcare security administration in their respective cities. The municipal healthcare security administrations shall consolidate these submissions and report them to the Provincial Healthcare Security Administration. Provincial-level public medical institutions affiliated with central government ministries or departments and located in Jinan shall report directly to the Provincial Healthcare Security Administration. The Provincial Healthcare Security Administration shall either establish provisional prices or determine them through agreements with medical institutions, with a trial period not exceeding two years. Upon expiration of the trial period, for services included within the scope of medical insurance coverage, the Provincial Healthcare Security Administration shall announce official prices based on an assessment of service effectiveness, costs, revenues, and other relevant factors.

(1) Scope of Reimbursement. The Provincial Healthcare Security Administration shall determine whether “Internet+” medical services provided by designated medical institutions are included in the scope of basic medical insurance reimbursement. For those included, each pooling region shall establish the reimbursement standards at a level no higher than the price ceiling for public medical institutions as determined by the province.

“Internet+” medical services that are identical in content to offline services covered by health insurance payment and that adhere to the pricing standards of corresponding public medical institutions shall, upon completion of the requisite procedures, be included within the scope of health insurance payment and reimbursed in accordance with existing regulations. For “Internet+” basic medical services involving entirely new content and subject to government-regulated pricing, upon expiration of the two-year trial period, the Provincial Healthcare Security Administration shall determine whether to include them in the scope of health insurance payment, taking into comprehensive consideration factors such as clinical value, price levels, and the capacity of the health insurance fund. Municipal health insurance agencies shall carry out necessary modifications to information systems, promptly incorporate newly added “Internet+” medical items into the health insurance settlement system in accordance with the requirements of this Notice, and guide designated medical institutions in ensuring proper mapping between their systems and health insurance items, as well as in handling expense settlement and health insurance payment operations.

(II) Agreement Management. Healthcare security departments at all levels shall, in light of the characteristics of “Internet+” medical services, reasonably determine global budget control indicators, improve service agreements with designated medical institutions, adjust healthcare security information systems, and optimize settlement processes. Meanwhile, they shall strengthen supervision of medical services to support designated medical institutions in delivering standardized, convenient, high-quality, and efficient medical services through “Internet+” platforms. A sound exit mechanism for agreement management shall be established; for violations of agreements, measures such as regulatory interviews, ordered rectification within a specified time limit, suspension of settlements, refusal of payment, suspension of agreements, and termination of agreements shall be fully utilized to strictly enforce liability for breach of contract.

(3) Fund Supervision. Healthcare security departments at all levels shall strengthen fund supervision, incorporate the networking and online deployment of intelligent monitoring systems into the agreement management of medical and pharmaceutical service institutions, and comprehensively promote the application of intelligent healthcare security monitoring. Medical institutions and licensed physicians found engaging in fraudulent activities to defraud insurance funds shall be subject to administrative penalties in accordance with the law; cases suspected of constituting criminal offenses shall be transferred to judicial authorities.

Medical institutions providing “Internet+” medical services shall base their fees on the principles of informed consent and legal compliance, adhere to the principles of fairness, legality, and good faith, and disclose such fees in a clear and transparent manner. The price for an “Internet+” medical service covers all costs associated with that item; for examination and testing services where conclusions are issued by a third party, fees shall be charged in accordance with the prices of the entrusting party’s offline examination and testing items, without establishing separate items for remote diagnosis or imposing duplicate charges.Internet-based follow-up consultations provided by medical personnel at various levels are all charged at the price of general outpatient consultation services.; Relying on “Internet+” to provide family doctor services, services shall be delivered and fees settled in accordance with the content and standards stipulated in the contracted service packages. No additional or extra charges shall be imposed due to changes in the mode of service delivery. Patients receiving “Internet+” medical services shall pay fees based on the priced items executed by the invited party. Where multiple parties are involved, such as the inviting party, the invited party, and technical support providers, or where different departments within the same entity are involved, the allocation of revenues shall be determined through mutual negotiation among the relevant parties. Fee splitting or imposition of additional charges is strictly prohibited.

Healthcare security departments at all levels shall prioritize public medical institutions and strengthen routine monitoring and management of medical service prices. In cases where significant cost fluctuations occur following changes in the delivery mode of offline services, timely investigations shall be conducted, and any new situations or issues arising during implementation shall be reported to the Provincial Healthcare Security Administration. In light of the new patterns and characteristics of “Internet+” medical services, price and reimbursement policies shall be accurately interpreted in a timely manner through various news media, so as to reasonably guide public expectations, actively respond to societal concerns, and strive for understanding and support from all sectors of society.

These Implementation Opinions shall take effect from December 10, 2019, and remain valid until December 9, 2021.

Source: Shandong Provincial Healthcare Security Administration