Nicklaus Children’s Hospital is south Florida’s only licensed specialty hospital exclusively for children. The 309-bed nonprofit hospital is renowned for excellence in all aspects of pediatric medicine, with many programs routinely ranked among the nation’s best by U.S. News & World Report.
The hospital recognized the need for enhanced processing with the passage of the Florida Medicaid Enhanced Ambulatory Patient Grouping (EAPG) for outpatient services in 2017. This regulation required that all outpatient services rendered to patients on the same date of service include all services in one claim. As more and more Medicaid payers adopted the EAPG methodology, hospitals throughout Florida needed to adapt quickly to ensure payments could be processed in a timely fashion.
In order to address this, Nicklaus Children’s created a multi-departmental initiative, which included their revenue cycle and managed care departments, to analyze the scope of the problem and set goals focused on redesigning and automating workflows. The new processes they created combined claims per EAPG requirements, decreased rework, and increased cash realization.
Nicklaus Children’s Hospital reconfigured their EMR to include the financial auto combine feature to integrate data from multiple outpatient encounters. The auto combine process identifies charges on each encounter, then moves most charges to one encounter per day prior to claim generation. A daily EAPG report was created for the services that the new process did not include, enabling staff to complete any remaining manual work needed on a timely basis.
Standards work was created to streamline the entire process, and new policies regarding daily documentation and charge capture were created, communicated to providers and reinforced. These processes made it possible for most claims to go out properly combined the first time, significantly eliminating backend rework.
As a result, the hospital was able to reduce first-pass monthly denials due to EAPG from a baseline performance of 82% ($206K) denial rate to a 7% ($18K) denial rate. Automating workflows to combine outpatient encounters resulted in a significant reduction in rework and manual intervention. Now, less staff are needed to oversee the process, and the hospital has been able to reallocate staff to other value-added activities.
HIMSS is pleased to recognize Nicklaus Children’s Hospital for both their HIMSS Electronic Medical Record Adoption Model (EMRAM) Stage 7 revalidation and their HIMSS Outpatient Electronic Medical Record Adoption Model (O-EMRAM) Stage 7 revalidation.
“Nicklaus Children’s Hospital identified an unacceptable rejection rate in their EAPG claims,” said Philip Bradley, regional director, analytics, HIMSS. “Using data, Nicklaus identified a workflow issue and modified as needed and introduced further automation. As a result, Nicklaus improved the reject rate by 91%.”
“Stage 7 designation represents more than just the maturity of our technology, it validates the way in which our clinicians interact with the technology to make data-driven decisions and improve outcomes,” said Matthew A. Love, President and CEO, Nicklaus Children’s Health System, the hospital’s parent organization. “Achieving HIMSS Stage 7 represents a decade-long organizational commitment to continuous improvement surrounding technology and its use with the goal of putting the care of children and families first,” he said.
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