🇺🇸United States

Improper Payments and Questionable Care Quality Due to EVV Control Failures

2 verified sources

Definition

EVV was introduced because Medicaid in‑home services suffered from improper payments and questionable quality of care, including services billed but not actually delivered. When EVV controls are weak or not properly implemented, agencies face rework, corrective action plans, and potential repayments tied to poor documentation and disputes over whether visits occurred or were completed as ordered.

Key Findings

  • Financial Impact: 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
  • Frequency: Ongoing (improper payment cycles align with every billing cycle; audits and corrective actions recur annually or bi‑annually)
  • Root Cause: Federal oversight bodies cite longstanding fraud, waste, and abuse in PCS, including claims for visits that did not occur, partially completed visits, or services not matching care plans.[1][6] Where EVV data are incomplete, manipulable, or not actively monitored, those historical quality problems persist, creating repeated disputes, chart corrections, and costs to remediate deficient records.[1][6]

Why This Matters

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

Affected Stakeholders

Clinical supervisors and directors of nursing, Quality and compliance managers, Billing and utilization review staff, State surveyors and Medicaid auditors

Deep Analysis (Premium)

Financial Impact

$30,000-$150,000 annually per hospice organization in claim denials, administrative rework, and Medicaid compliance penalties for improperly documented waiver services • $40,000-$200,000 annually in claim payment delays, rework costs, dispute resolution with home care agencies, and potential fraud-related investigation expenses tied to improper PCS billing • $50,000-$250,000 annually per organization in denied claims, corrective action plan administration, and re-audit costs from Medicaid waiver program funding loss

Unlock to reveal

Current Workarounds

Manual spreadsheets and phone calls to verify visit completion; WhatsApp/text message confirmations from workers; memory-based reconciliation between scheduler records and EVV system; email chains documenting exceptions; hand-written exception logs • Manual verification calls to agencies providing services; spreadsheet-based visit reconciliation; email documentation of visit confirmation; paper-based exception tracking • Separate manual tracking for Medicaid beneficiaries vs. Medicare beneficiaries; WhatsApp confirmations from field staff; spreadsheet reconciliation of visits and billing records; email-based exception management

Unlock to reveal

Get Solutions for This Problem

Full report with actionable solutions

$99$39
  • Solutions for this specific pain
  • Solutions for all 15 industry pains
  • Where to find first clients
  • Pricing & launch costs
Get Solutions Report

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)

Delayed Reimbursement from EVV‑Related Claim Holds and Denials

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

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

Request Deep Analysis

🇺🇸 Be first to access this market's intelligence