🇺🇸United States

Improperly Paid Home Care Claims Due to Missing or Defective EVV

2 verified sources

Definition

States are paying large volumes of home health and personal care claims without required EVV verification, exposing agencies to later recoupments and denials. New York’s Medicaid program paid billions for services that either lacked EVV or used unverifiable EVV records, indicating that providers were being reimbursed on non‑compliant data that can be clawed back.

Key Findings

  • Financial Impact: $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
  • Frequency: Monthly (identified over a 26‑month audit period and tied to ongoing claims cycles)
  • Root Cause: Weak EVV oversight and monitoring allowed claims to be paid even when EVV was missing, incomplete, or manually altered without documented justification, so billing systems did not reliably link claim payment to compliant EVV data.[1][4] The Comptroller found the Department of Health lacked an effective EVV compliance program to deny improper claims and recoup overpayments.[1]

Why This Matters

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

Affected Stakeholders

Home health agency owners and executives, Revenue cycle and billing managers, Medicaid compliance officers, State Medicaid program integrity staff

Deep Analysis (Premium)

Financial Impact

$100,000-$300,000 annually in claim denials per agency • $100,000-$300,000 annually per agency • $120,000-$350,000 annually per agency

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Current Workarounds

Manual audit, staff rework coordination, Excel tracking • Manual defect tracking, rework requests, re-audit • Manual rework, re-entry in EVV system

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Methodology & Sources

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

Evidence Sources:

Related Business Risks

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

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

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