EPSDT’s Impact on Medicaid Audits
Posted by kemanuel
Because the breadth of EPSDT is so large and covers so many Medicaid recipients under 21, many NC auditors conducting Medicaid audits are either overlooking the importance of EPSDT or lacking the comprehension of the ever-arching arms of EPSDT.
First, what in the heck is EPSDT? It’s an acronym for Early and Periodic Screening, Diagnostic and Treatment.
The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services.
|Early||Assessing and identifying problems early|
|Periodic||Checking children’s health at periodic, age-appropriate intervals|
|Screening||Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems|
|Diagnosis||Performing diagnostic tests to follow up when a risk is identified, and|
|Treatment||Control, correct or reduce health problems found.|
How EPSDT works in real life:
The simplest way to think about EPSDT, is to throw out all entrance criteria for whichever Medicaid service is at issue (as long as the Medicaid recipient is under the age of 21). (Please understand that this is not the legal standard for EPSDT).
The way North Carolina explains EPSDT in the DMA Clinical Policies is as follows:
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement that requires the state Medicaid agency to cover services, products, or procedures for Medicaid beneficiaries under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination** (includes any evaluation by a physician or other licensed clinician). This means EPSDT covers most of the medical or remedial care a child needs to improve or maintain his/her health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
For example, if, in order to receive Medicaid services for X the Medicaid recipient must meet criteria A, B, and C, but only meets A and B, the Medicaid recipient can still receive the services if the recipient is under 21 and:
- The Medicaid recipient can show that the services are medically necessary to correct or ameliorate a medical condition.
Ok, you understand the definition of EPSDT. But how does EPSDT come into play during a Medicaid audit?
Many audited services have undergone prior authorization by the contracted company for DMA. For example, for mental health services, prior authorization comes from ValueOptions (VO). Then years later, the Carolinas Center for Medical Excellence (CCME) or other recoupment auditing contractor (RAC) audits the same services that were previously authorized, and, in many cases, decides that medical necessity was not met because the entrance criteria had not been met.
The difference in opinion between VO and CCME, in many cases, is a lack of understanding the strength of EPSDT.
Time and time again, I have gone to reconsideration reviews when the Medicaid recipients were all under 21 and argued that medical necessity was met through EPSDT. Yet, time and time again, the RAC (whether CCME or Public Consulting Group (PCG)) representative vehemently disagrees that EPSDT is applicable. He or she argues that the entrance criteria must be met regardless.
Because, in my past life, I actually worked for the Attorney General’s office in the Medicaid department, I saw hundreds of hundreds of decisions from the Office of Administrative Hearings (OAH) stating that medical necessity was met via EPSDT. In some cases, the Medicaid recipient had not even met one entrance criteria for the Medicaid services. But EPSDT has been interpreted to be extremely broad and encompassing.
Despite the importance of EPSDT, it appears that no one explained this to the contracting companies conducting the NC Medicaid audits. Perhaps someone should tell them….
About kemanuelMedicare and Medicaid Regulatory Compliance Litigator
Posted on February 25, 2013, in CCME, Division of Medical Assistance, EPSDT, Health Care Providers and Services, Medicaid, Medicaid Audits, Medicaid Eligibility, Medicaid Recipients Under 21, Mental Health, Mental Illness, North Carolina, OAH, PCG, RAC, Reconsideration Reviews and tagged Audit, Community mental health service, EPSDT, Medicaid, Mental health, North Carolina, Public Consulting Group, ValueOptions. Bookmark the permalink. 7 Comments.