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Pricing in clinical biology

Determining the cost price of a laboratory test can sometimes be complicated and involves more than simply adding up the cost price of the individual tests. We outline the most important principles below.

The nomenclature of medical services

In the nomenclature of medical services, a number of items are reserved for laboratory medicine. Laboratory medicine is defined by the RIZIV as clinical biology, anatomical pathology, and genetics.

Each of the services has two nomenclature numbers: one for outpatients and one for hospitalized patients.

Cumulative rules prohibit the simultaneous billing of combinations of nomenclature numbers.

Diagnosis rules limit the RIZIV reimbursement to certain diagnosis groups such as PSA (only twice a year in follow-up or once a year for patients over 40 with a family history).

Tests that are not covered by RIZIV reimbursement are charged to the patient.

Each service is assigned a B value. This is a measure of the cost price or fee of a service. For example, the determination of glucose in blood has a B value of B50. Currently, 1 B value corresponds to €0.0309. The fee for glucose is therefore 50 x €0.0309 = €1.54.

Pricing for outpatients

The full cost of a laboratory test (contribution from the RIZIV + any co-payment for the patient) for outpatients is determined by two components:

  • 25% fee per service For each analysis performed, 25% of the cost is paid by the RIZIV as a fee. In the example of glucose, the RIZIV therefore pays 0.25 x €1.54 = €0.39.
  • Flat-rate fee per prescription/24 hours To determine the flat-rate fee that may be charged, the sum of the B values of all requested analyses is calculated per prescription. The reimbursement by the RIZIV and therefore the patient's co-payment depends on the sum of the B values and whether the patient is eligible for a preferential arrangement. This only applies to services provided under Articles 3, 18, and 24. For services provided under Articles 24bis and 33bis (e.g., PCR for STIs), 100% of the cost price is granted as a fee.

Tariffs for hospitalized patients

The tariff for a laboratory test for a hospitalized patient is not only determined by the fees per service provided by the laboratory, but also by flat-rate fees per admission to the hospital and flat-rate fees per day of hospitalization.