🇺🇸United States

Poor Strategic and Operational Decisions from Underused or Unreliable EVV Data

2 verified sources

Definition

Although EVV generates rich data on visit patterns, many agencies and some states lack the analytics maturity to use it effectively, leading to missed opportunities to detect fraud, optimize scheduling, or improve care. State audits have highlighted risks that EVV records can be manually altered without trace, undermining data integrity and any decisions based on them.

Key Findings

  • Financial Impact: Latent but material: missed fraud detection and operational optimization opportunities worth millions at the state level (e.g., New York’s $14.5B in payments without required EVV verification represent a massive blind spot) and substantial margin loss for individual agencies that could otherwise use EVV data to reduce overtime and travel inefficiencies
  • Frequency: Continuous (each reporting and planning cycle that ignores or mistrusts EVV data reinforces suboptimal decisions)
  • Root Cause: The New York Comptroller’s audit noted that there is a risk to the integrity of EVV records when submitters can manually adjust them without the Department of Health’s knowledge or a documented reason, compromising the data’s reliability for compliance and management decisions.[1] CMS and OIG are still in the process of evaluating EVV data availability and completeness for program integrity purposes, indicating that many states have yet to fully leverage EVV data to guide policy and provider oversight.[1][6]

Why This Matters

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

Affected Stakeholders

State Medicaid analytics and program integrity teams, Agency executives and operations leaders, Scheduling and workforce management analysts, Compliance officers relying on EVV dashboards

Deep Analysis (Premium)

Financial Impact

$100K-$250K annually through higher insurance premiums (5-10% uplift due to unproven risk controls), claims denials from audit findings, and staff time spent on manual reporting and dispute resolution • $100k-$300k per PT annually (claim denials, appeal overhead, lost revenue from slow reimbursement) • $100k-$300k per social worker annually (claim denials, audit overhead, compliance labor)

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Current Workarounds

Agencies maintain separate Google Sheets or Word docs to 'explain' discrepancies; manual phone calls to recreate missing check-in/out data • Agencies track actual hours worked in separate time system (Homecare Homebase, Paylocity) that does NOT match EVV records; manually adjust bills offline • Agency calls HHA 'after the fact' to recreate missing or altered EVV records; HHA provides phone-call confirmation; agency re-submits claim

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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

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)

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