Outpatient Hospital Payment

Enhanced Ambulatory Patient Groups (EAPG)

The Department of Health Care Policy & Financing (the Department) implemented the Enhanced Ambulatory Patient Grouping System for October 31, 2016. Enhanced Ambulatory Patient Groups (EAPG) weight tables are provided for reference by various healthcare partners and providers. The relative weight tables are used by the Department to reimburse hospitals for outpatient services. The Department has compiled a list of Frequently Asked Questions for providers and for Health First Colorado members regarding the implementation.

EAPG Weight Tables

EAPG Hospital-Specific Base Rates

Communication 

The Department has provided progress updates via email to its hospital provider community regarding Colorado interChange claims processing and EAPG pricing. Please see below links for copies of these letters.

Billed Amount Redistribution Logic

The Department has worked with 3M on updating the “lower of” pricing logic which compares EAPG payment to line item submitted charges. This update, which will be effective October 31, 2016 and was released as part of 3M’s October 12, 2017 service pack release, will utilize the EAPG grouper to redistribute billed amounts by visit prior to the “lower of” pricing comparison between EAPG payment and line item submitted charges. This change will make payments under the EAPG methodology more in alignment with initial payment projections. See below for an attachment providing greater detail for this update.

EAPG Billed Amount Redistribution 

For any questions regarding the billed amount redistribution logic, please email HCPF_Hospitalregulatory@state.co.us.

Licensing

Hospitals will not be required to purchase the EAPG software to facilitate the implementation of EAPGs. The EAPG grouper specific to Colorado Medicaid will assign the EAPGs to the claim lines and calculate the payment within the Department’s MMIS system. Hospitals may choose to purchase the EAPG grouping software allowing them to project revenue. For sales inquiries, please contact 3M Health Information System. For licensing the EAPG Definitions Manual, please see the 3M EAPG Definitions Manual Order Agreement

Engagement Meetings

Starting in 2019, the EAPG meetings have been merged back into the Hospital Stakeholder Engagement Meeting. For the Hospital Stakeholder Engagement Meeting schedule visit our Hospital Stakeholder Engagement. For information regarding any meetings prior to 2018 please contact Elizabeth.Quaife@state.co.us

 

Policy Decisions

The Department presented documents during the informational meetings containing the policy decisions required for the implementation of the EAPG system.

For all questions relating to the implementation of EAPGs, please contact the Department at HCPF_Hospitalregulatory@state.co.us.

As part of the HB 09-1293 provisions, the Department of Health Care Policy and Financing (the Department) is authorized to develop and implement improvements to the current hospital payment methodologies, including but not limited to the development of incentive payments, implementation of new payment systems, and rate reform.