🇺🇸United States

Delayed Reimbursement from EVV‑Related Claim Holds and Denials

3 verified sources

Definition

Medicaid claims lacking required EVV data or containing mismatches (time, location, caregiver ID) are subject to denial or suspension, slowing cash inflows to home health agencies. States have made clear that non‑compliant claims can be denied once EVV mandates are in force, directly affecting Days Sales Outstanding and liquidity.

Key Findings

  • Financial Impact: Cash flow delays equivalent to 30–90 days of Medicaid receivables for affected claim volumes; for a $10M‑revenue agency with 70% Medicaid, this can mean $1–2M temporarily locked in AR when EVV defects spike
  • Frequency: Daily to weekly (as claims batches hit state Medicaid systems and are rejected or pended for EVV issues)
  • Root Cause: The Cures Act and CMS guidance allow states to deny claims that do not meet EVV requirements.[2][4] Legal advisories warn providers that states and CMS are actively auditing EVV submissions and that overpayments identified through EVV review can lead to repayment demands and False Claims Act exposure, incentivizing aggressive claim holds when EVV data look incomplete or inconsistent.[1][7]

Why This Matters

This pain point represents a significant opportunity for B2B solutions targeting Home Health Care Services.

Affected Stakeholders

Revenue cycle managers, Billing specialists and claim scrubber teams, Agency CFOs and controllers, Medicaid liaison and provider enrollment staff

Deep Analysis (Premium)

Financial Impact

$100K–$300K annually (20–30% of new-hire first-visit claims rejected due to EVV errors; rework burden; lost productivity during remedial training) • $120K–$350K annually (Medicaid waiver claims denied due to caregiver EVV errors in first 30–60 days; higher error rates for new hires; compliance risk and potential state sanctions if non-compliance patterns detected) • $150K–$400K annually (claim suspension/denial cycles for 500–1000 visits/month at $150–$400 per denied claim)

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Current Workarounds

Compliance Officer manually runs SQL queries or exports from EVV system; compares against claim submissions in spreadsheets; escalates findings via email and in-person meetings; corrects records ad-hoc • HR sends EVV training slides via email or uses ad-hoc in-person sessions; no tracking of training completion; caregivers learn from peers or figure it out on first day; HR discovers compliance gaps only when claims denied • HR/Recruiter passes new hire to scheduler or clinical manager for 'informal' EVV setup; no formal training record; caregiver learns by trial-and-error or from peers; compliance gaps discovered when claims audit begins

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Methodology & Sources

Data collected via OSINT from regulatory filings, industry audits, and verified case studies.

Evidence Sources:

Related Business Risks

Improperly Paid Home Care Claims Due to Missing or Defective EVV

$14.5 billion in New York Medicaid PCS payments without required EVV verification over 26 months; $31 billion total PCS/HHCS payments in audit scope at risk for claim denials or recoupment

Increased Administrative and Technology Costs to Achieve EVV Compliance

$10,000–$100,000+ per year per mid‑size agency in licenses, devices, IT/integration, and compliance staff time (industry estimates; specific dollar ranges inferred from multi‑state adoption and mandated system build‑outs)

Improper Payments and Questionable Care Quality Due to EVV Control Failures

Tens of millions per state annually in improper PCS/HHCS payments and related remediation costs (re-audits, corrective action, internal reviews) attributed to weaknesses EVV is designed to prevent

Field and Back‑Office Capacity Lost to EVV Documentation and Exception Handling

Hundreds of non‑billable staff hours per month for a mid‑size agency (equivalent to $5,000–$20,000/month in labor cost and lost productive time, depending on wage levels and scale)

EVV‑Driven Overpayment Recoveries, FMAP Reductions, and False Claims Exposure

Statewide: FMAP reductions of up to 1% of Medicaid PCS/HHCS expenditures; Provider‑level: repayment of improperly paid claims plus potential treble damages and civil penalties under False Claims Acts (often translating into multi‑million‑dollar settlements in analogous Medicaid fraud cases)

Legacy and Ongoing Fraud Schemes in Home Care Despite EVV

Nationally, improper payments and fraud in PCS/HHCS were large enough to justify federal legislation; state audits like New York’s show tens of billions in payments at risk for fraud and abuse scrutiny over just a two‑year window

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