Benefiting fraud reduction & agency operations
by Greg Lotz

When Congress passed the 21st Century Cures Act in December 2016—which mandated Electronic Visit Verification (EVV) for all state Medicaid-funded services—EVV became a reality for many home health agencies across the country. Although EVV can bring many accuracy- and efficiency-related benefits, no business likes to have processes forced upon them.

Even though many states have chosen to fund their selected system’s total acquisition cost, there are typically new operational costs associated with the chosen system. Health care organizations that bill services to state Medicaid are left with the added expense of retraining their workforce. In some cases, due to poor system configuration decisions at the state level, they are also faced with higher administrative costs and increased bill-to-cash-flow timelines when EVV should result in the exact opposite effect.

Cures Act Mandate

To meet the requirements of the Cures Act and avoid federal reduction of Medicaid annual funding by 2% for non-compliance, Medicaid-implemented systems must verify at least these items:

  • Type of service performed
  • Individual receiving the service
  • Individual providing the service
  • The date the service was provided
  • Location of service delivery
  • Time the service begins and ends

There are many types of EVV systems in the market that can achieve a reliable collection of this data. The most frequently used are:

  • Smartphone apps that use a global positioning system or radio-frequency identification
  • In-home devices that generate a new code every minute
  • Telephony (that is, a plain old telephone solution). With telephony, field staff use the beneficiary’s home phone to call an 800 number and record start time, end time and various other data elements through multiple means that vary by vendor and state requirements.

Types of Systems

State Medicaid organizations have the flexibility of selecting their chosen method for implementation. The naming conventions used throughout the country for these methods seem to vary by location, but it all boils down to three types of implementation.

Closed System

No integrations to the contracted vendor are permitted and everyone must use that contracted system. Fortunately, there are only a few states that have chosen this path. This method makes it administratively burdensome for provider agencies to use the software they’ve already invested in to manage their operations and to also use the mandated other system. This also limits available technology to whatever that vendor has contracted.

Open System

Typically, the state will communicate the minimum requirements, possibly build or contract to create an aggregator for the data that selected systems must integrate to, and leave the acquisition up to the provider agency.

Hybrid System

This has been the most common type implemented to date. The state typically selects and funds one or more EVV vendor system(s) for provider agencies to utilize at no cost if they choose. The state then also requires the contracted vendor(s) to support integration with existing vendors that provider agencies may already be using to reduce the training and administrative burdens that forcing a new system can cause.

Many electronic medical records and agency management software on the market today already have a proprietary Cures Act-compliant EVV system. Those that don’t are often integrated with an EVV vendor that is Cures Act compliant. For this reason, either an open or a hybrid system is generally preferred. It can significantly reduce the cost impacts caused by imposing a closed system upon provider agencies, the associated retraining and the potential staffing increases required to operate consistently in two disparate software platforms.

Claims Processing Issues

A further issue the industry is experiencing as EVV gets implemented across the country is that some state Medicaid organizations are implementing systems—regardless of type—that validate the claim submission before it is submitted for payment instead of after submittal and before payment. This injects a dramatic increase in complexity that, in this writer’s opinion, has yet to result in gains in inefficiency. Agencies in states that currently force this requirement are experiencing large-scale failures in what should be successful claims submission. This is typically driven by contracted EVV vendors requiring claims generation within their software, often with limited access unless the agency purchases enhanced functionality from the vendor. In several state-mandated systems, the managed care organization’s authorization validation process is brought up front, which further complicates the process.

The most effective configurations to date leave the existing claims submission process in place. Only after those current processes are completed does the EVV data get matched in the aggregator for final claims payment approval. This leaves the already complex claims approval and appeal processes where they were. Then, once a claim successfully navigates that existing process, EVV data is matched to determine if the claim can indeed be paid. This makes it far easier for agency billing staff to identify and fix whatever issue may be preventing the claim from being paid.

Unfortunately, several Medicaid organizations have believed promises from contracted EVV vendors that they would simplify claims processing by using EVV to screen at the time of billing. Time and again, this methodology is failing. Typically, the contracted vendors are holding the provider hostage in this process to force them to buy a full software package to alleviate the claims bottleneck. The minimal system the contracted EVV vendor has sold to the state doesn’t work well for billing and claims management, leaving providers on the hook for the claims.

Benefits of EVV

Electronic visit verification, when properly implemented, can bring a host of benefits to providers, Medicaid beneficiaries, and state Medicaid funds availability. Agencies know whether or not the service provider is indeed at the home and can react and replace staff to ensure proper service provision. Agency administrative staffing in billing, payroll and scheduling can often be reduced or redeployed, and the timeline from service provision to claim submission can be reduced significantly. EVV has been proven time and again to reduce fraudulent claims submissions, often to the tune of millions of dollars per year.

When your state sends out surveys for input on what system types would be preferred, make sure to share your thoughts and to help generate a win-win in your state for EVV implementation. Remember, these initial implementations in most states are for aide services only; skilled services are targeted for January 2023. We need to get it right the first time.

Greg Lotz, KanTime’s director of sales and marketing technology, has been engaged in electronic visit verification and health care technology for nearly 10 years. He is deeply involved in KanTime’s integrations with multiple vendors to help customers meet state-mandated EVV guidelines.