Why State Medicaid Programs Need To Be EVV Audit-Ready Now
The use of Electronic Visit Verification (EVV) has been a home care compliance requirement for years. Signed into law in 2016 with the 21st Century Cures Act, this piece of legislation requires EVV to be used for all Medicaid-funded personal care services and home health care services.
By now, the EVV adoption grace period has ended for every single state, and enforcement is in full swing. The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) are keeping a close watch on compliance and data integrity, with audits occurring on a rolling basis.
For home care agencies under scrutiny, EVV software is the best way to stay on top of evolving regulations and embed compliance checks into the visit logging process. Read on to understand what’s at stake for agencies that don’t meet expectations, and how to make sure you stay on the right side of compliance.
Why EVV Audit Readiness Matters More Than Ever
States are now responsible for proving that they are enforcing EVV data standards, not just collecting information and stowing it away. On the ground, governing bodies are closely monitoring agencies’ adherence to both federal and state EVV requirements; meanwhile, whistleblower cases are becoming increasingly common, as individuals who report fraud can get a cut of the recovered funds.
In the event of non-compliance, the impact can be calculated in dollars and cents. Federal Medical Assistance Percentages (FMAP) reduction penalties are 0.25% in the first year, with incremental increases up to 1% in subsequent years.
While 1% might not seem like much at first glance, it can add up to millions or hundreds of millions in lost federal funding, depending on the state. As these losses pile up, states may choose to send the cost downstream through tighter reimbursement policies or stricter contracts with agencies.
Organizations that fail to comply with EVV regulations are vulnerable to a number of consequences, depending on the situation:
- Fines or other financial penalties
- Clawbacks that require repayment of over-billed claims
- Name included in public OIG reports
- Name included in state Medicaid exclusion/sanction lists
- Increased bonding and insurance costs
- Reputational damage that deters referral sources, clients, and new hires
- Losing provider status if too many violations pile up
The actual outcome can vary based on who is receiving the penalty. For state-level programs, FMAP may require a corrective action to be submitted to CMS, or simply place the state under “high-risk” oversight. The reputation risk of being published in a public OIG filing is significant, and in the future, states under close surveillance may also be subject to more frequent audits.
For home care providers, the direct financial hit from denials and recoupments can be catastrophic, alongside the operational disruptions that come with an audit. The loss of MCO contracts can be even more painful than state penalties, and in the very worst-case scenario, program exclusion can lead an agency to shutter its doors.
Key EVV Requirements Under Medicaid
Each state must decide which EVV model they want to adopt. Closed-model states mandate a single EVV provider that all home care agencies must use, while open-model states give agencies the option to select their own vendor. No matter the setup, every agency’s EVV system must capture the same six data elements for every visit:
- Type of service performed
- Individual receiving the service (client)
- Date of service
- Location of service delivery
- Individual providing the service (caregiver)
- Time the service begins and ends
While GPS verification via mobile app is the most common and accurate way to log a caregiver’s location, some states also allow this step to be completed using a landline phone or fob. The frequency and format of data submission can also vary by region, and some states require additional information (tasks performed, mileage, etc.) to be submitted.
Common EVV Audit Risks & Compliance Gaps
During the audit process, auditors will be combing through visit information to ensure each caregiver’s identity is matched to a valid worker, each client identity maps to a recipient with on-file authorizations, that each visit actually occurred, and that the caregiver-client pairing makes sense.
Entries must be time-stamped correctly and validated by GPS, with electronically captured clock-in/clock-out times and visit durations that match the care plan. There must be no overlapping visits that show the same caregiver in two places at once, and each edited entry must include a justification.
Each service rendered at the client’s residence must align with care plan recommendations and be properly mapped to the relevant service code on the associated claim. Each bit of documentation must also support medical necessity where required.
Auditors keep an eye out for certain red flags that may indicate dishonest reporting, such as a high volume of manual edits or exception rates. Visits backdated days after delivery may raise a flag, as well as caregivers working shifts that seem unreasonably long. Clusters of identical visit durations may look fabricated, as would caregiver visits to clients they aren’t authorized to serve.
The best way to reduce compliance risk and support audit-readiness is to use an EVV software designed for home care success. A purpose-built platform will automatically check for missing information, capture essential data in real time, and sync field operations with back-office systems to ensure work completed maps to work authorized.
Build an EVV Audit-Ready Process
Audit-readiness should be something that’s embedded into daily operations, not a catch-up task that’s completed on a scheduled basis. At any moment, every single visit or data point being produced by an agency should be able to hold up against an auditor’s inspection.
EVV implementation best practices begin with mandated clock-ins and clock-outs at the point of care, on a mobile device and supported by GPS. Except for documented exceptions like a lost phone or dead device, retroactive entries should not occur. That includes checking off tasks during the visit itself, as opposed to later on.
Before a claim is sent off to a payer, your EVV system should scrub the data to check for missing elements, location issues, overlapping visits, and any mismatches between what’s been billed and what was authorized. If a visit is flagged with an error, it must be reviewed by a team member instead of being submitted automatically.
Every time someone manually edits an EVV entry, it leaves room for a mistake to slip through. To avoid unnecessary risk, assign role-based permissions that limit who can change information. If manual edits become the easy default answer, compliance will suffer as a result.
To ensure these systems are working as intended, periodic self-audits can detect areas for improvement and highlight which functions are running smoothly.
- Weekly: Review exception reports and unresolved visits to make sure every loop has been closed.
- Monthly: Take a random sample of client visits and compare visit records vs. care plans vs. claims.
- Quarterly: Run a mock audit against your state’s most up-to-date Medicaid criteria.
- Annually: Sit leadership down for a full compliance review.
Train Staff on EVV Compliance Requirements
Since caregivers uphold EVV on the front line, they need to be trained in-depth on the purpose and value of proper implementation. A single handout won’t suffice; agencies need a full onboarding plan plus refresher sessions whenever state rules change or your software updates its features.
Office staff have a different set of EVV training requirements that includes proper editing policies and documentation protocols. It’s best to appoint a designated EVV compliance “owner” who has the authority to enforce standards and take accountability for overall implementation.
Both caregivers and office staff need to understand the “why” behind EVV, not just the “how.” Knowing the risks and consequences of not fulfilling its requirements gives meaning to the process and will encourage staff to take it seriously.
Ultimately, agencies should strive to create a proactive culture of compliance: staff should be encouraged to flag issues with the system, be rewarded for submitting clean data, and feel empowered to execute EVV properly in the field through comprehensive ongoing training.
How AxisCare Supports EVV Audit Readiness
There are plenty of benefits associated with EVV beyond compliance and reducing regulatory risk. AxisCare embeds EVV capabilities directly into its software platform, seamlessly connecting to state aggregators to place compliance at the heart of agencies’ home care operations.
Our mobile app makes it easy for caregivers to clock in and clock out with GPS support, plus an added layer of biometric verification. These data points make it clear that the right person was on location at the right time, delivering safe and authorized services to the client.
By standardizing the process of capturing visit information, EVV eliminates process variation to produce cleaner and more complete data that is easier for auditors to query. That same well-organized data is used by the billing team to send claims, reducing the likelihood of denials due to missing or incorrect information.
When all of this data is fed through the same software system, the dots connect themselves: EVV data captured on the spot proves that caregivers are exactly where they need to be, administrators can align service data with the recommendations outlined in the care plan, and only authorized services will then be sent off to Medicaid and other payers. In the event of an audit, these connections are airtight.
Stay Ahead of EVV Audits
Audit-readiness is an ongoing practice and a team-wide effort. Making sure your frontline and back-office staff are well-trained and aware of the meaning behind EVV is essential for obtaining their buy-in, and in turn, upholding compliance day-to-day.
It all starts with an EVV software that’s intuitive and easy to use, with a feature suite that supports operational excellence. Request a demo with our team to find out how AxisCare helps agencies across the United States stay ready for any audit that comes their way.
