The mission of the Maryland Health Kids/EPSDT Program is to ensure access and availability of quality health care for Medical Assistance children, teens and young adults less than 21 years of age. The goal of the program is to provide appropriate practice-based performance improvement assessments and targeted interventions to enhance the quality of health services delivered by Medicaid providers to eligible recipients less than 21 years of age. Throughout the 2015 calendar year, the Delmarva Foundation performed an annual medical record review of preventive services, according to the calendar year’s Schedule of Preventive Health Care for HealthChoice children under the age of 21.
The medical data abstraction was performed by trained nurse reviewers who had access to the enrollee’s entire medical record. The sample frame was drawn using random sampling methodology. The CY 2015 EPSDT medical record review included encounter data for services performed from January 1 through December 31, 2015. The chart audit is to ensure these recipients received the EPSDT services entitled to them under the federal and state guidelines. After completion of the audit process, the individual provider receives their score.
The chart audits are compiled and separated by membership within the various managed care organizations. The Managed Care Organization then receives a composite score. There are five areas that comprise the composite score:
- Health and Developmental History
- Comprehensive Physical Exam
- Laboratory Tests/At Risk Screenings
- Health Education/Anticipatory Guidance
The Managed Care Organization must receive an 80% or better for each component, which is required for a satisfactory finding. For 2016 (based on CY 2015 medical records), MedStar Family Choice is pleased to report that our composite score was 90%, which is a 2% increase from last year. Furthermore, it is also 1% above the Maryland HealthChoice Aggregate. Moreover, there were no individual areas where our score was less than the 80% threshold. You and your staff should be very proud of these results.
Areas in which the MedStar Family Choice scores increased are Health and Development History which increased from 91% in CY 2014 to 93% in CY 2015. Laboratory Tests/At Risk Screenings increased from 73% in CY 2014 to 81% in CY 2015. It should be noted that a collaborative effort between the Maryland Department of Health (formerly DHMH) and MedStar Family Choice found the score was understated for CY 2014. Therefore, the increase to 81% in CY 2015 may not represent a substantial change from the actual performance in past years.
Health Education/Anticipatory Guidance increased from 92% in CY 2014 to 93% in CY 2015. Comprehensive Physical Exam was 94% in both CY 2014 and CY 2015. Immunizations decreased from 83% in CY 2014 to 82% in CY 2015.
MedStar Family Choice continues to remind you that Laboratory Tests/At Risk Screening requires extra attention. Under this component various screening are included in the scoring. For example: Tuberculosis, Anemia, Heart Disease/Cholesterol, Blood Lead Testing, and STD/HIV in adolescent recipients. We also want you to know there is emphasis on calculating and graphing Body Mass Index (BMI) for all children 2 to 20 years of age along with the graphing of weight and height.
MedStar Family Choice realizes that not all lab tests are required when a child does not exhibit signs of risk but providers must continue to document these findings. We encourage our providers to continue to utilize the EPSDT "Preventative Screen Questionnaire". This form was designed to help primary care providers identify children who are at risk for these diseases and require further screening. The tool also identifies children who are not at risk and do not need further labs at that time. By using this form, the nurse reviewers will be able to easily see that appropriate screening questions were reviewed with the patient. This should help improve your audit results, as well as ours. If you would like a copy of any of the EPSDT forms you can go to the EPSDT website or contact our Provider Relations Department at (410) 933-3069 and a supply will be provided to you.
For CY 2016 medical record review cycle, the Maryland Department of Health has again contracted with the Delmarva Foundation to perform the medical record reviews. Delmarva nurses will be contacting your offices to set up appointments to review the records. MedStar Family Choice would like to thank you for your cooperation.