Equitable Pricing Model
The Equitable Pricing Model (EPM) is a proprietary algorithm developed and used by Palmetto GBA® and other contractors affiliated with the MolDX® program to establish Gapfill pay rates. Its purpose is to determine an accurate price for a molecular pathology service that is fair and equitable (as much as is possible) using available data in accordance with CMS instruction. Test price accuracy in the scope of this model is defined as a price that does not inhibit a provider from performing a reasonable and necessary service, while at the same time preventing excessive or exorbitant reimbursement which is not consistent with our fiduciary responsibility to the Medicare trust fund or preclude accurate pricing of other, subsequent tests. This EPM model seeks to minimize arbitrary pricing and improve price reproducibility by establishing a framework around established pricing guidelines/consideration requirements defined in 42 CFR 414 subsection G:
(A) Charges for the test and routine discounts to charges;
(B) Resources required to perform the test;
(C) Payment amounts determined by other payors;
(D) Charges, payment amounts, and resources required for other tests that may be comparable or otherwise relevant; and
(E) Other criteria CMS determines appropriate.