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In the home care industry, Electronic Visit Verification (EVV) serves as a crucial requirement for Medicaid-funded agencies. Mandated by the 21st Century Cures Act, EVV is not merely an optional feature but an essential component of services. Providers conducting in-home visits as part of a care plan are required to utilize EVV to record and verify visit data electronically. Rather than being seen as a constraint, though, EVV presents an opportunity for home care providers to enhance their work and reputation by adding an additional layer of defense. By utilizing an advanced, fully-integrated EVV solution, agency owners and operators can effectively safeguard their business’ health and maximize the potential for continued success. 

While EVV has enabled the home care industry to eliminate its reliance on manual and paper-based processes for recording and monitoring service delivery, its full influence extends far beyond those achievements. In addition to complying with federal regulations, the technology validates the care that home care workers provide, which positively impacts their agencies’ efficiency and reputation. EVV acts as a safety net to ensure agencies stay at the cutting edge of patient care as it verifies every service and interaction, boosting the likelihood of claims being accepted and paid while orchestrating a more synchronized and responsive care continuum. 

Payments for EVV-mandated services are at risk if EVV’s real-time documentation of a home care visit cannot be substantiated or if it cannot be properly linked to the service as indicated on a submitted claim. The primary risk in many markets lies in the separation of the claims process from the EVV process, particularly in the area of claims matching. Challenges can arise when these two processes are kept separate and distinct, particularly when visit data does not match claims submission data, or if comparative data is out of sync — as would be the case with visits that weren’t supported by EVV.

EVV compliance requires the right system and a trusted partner

EVV-related risks aren’t always easy to spot, as they’re often disguised within the complexities of home care service delivery. What might seem like a minor deviation from EVV requirements can snowball into a stressful situation leading to rejected billing claims and recoupments as well as fraud, waste and abuse allegations. If an audit is triggered, depending on the severity of the findings, it could lead to serious repercussions, such as higher levels of scrutiny from oversight organizations such as the Office of the Medicaid Inspector General or attorney general, removal from provider networks and programs, loss of certification or ability to operate, and even legal action. 

Fortunately, the potential for such severe consequences can be significantly minimized with the usage of a reliably effective and convenient EVV platform. However, not all systems are created equal. Successfully implementing EVV is akin to assembling the components of a high-performance engine that drives a finely-tuned, efficient machine; establishing an airtight safety net necessitates the use of appropriate tools in the hands of skilled professionals. Providers should opt for software that includes pre-bill or pre-claim generation edits that verify EVV’s presence and accuracy before a claim is generated, thus decreasing chances of the claim being rejected or paid erroneously by the payer and then later recouped. HHAeXchange’s system, for example, is built on the premise that EVV exists on a shift. When it’s not present and the visit must be manually documented, it’s considered an exception. Exceptions must include corresponding explanations stating a reason for the visit’s manual documentation, also known as a “visit edit reason” in the home care industry.

Most states accept visit edit reasons, as the need does occasionally arise, but their usage should be rare, monitored and well-documented. Whenever possible, EVV should be allowed to carry the load, acting as a safety net to ensure verified service delivery and combat against the possibility of fraud, waste and abuse suspicions. EVV-backed claims are more than transactions; they’re narratives of care documenting actionable steps taken toward improving health outcomes. The trustworthy platform generates industry-standard documentation, demonstrating home care agencies’ compliance and their commitment to transparency. Given the significant impact and influence of such a system, providers’ EVV software choices are critical. 

To ensure the highest level of support and protection, solutions should enable pre-bill or pre-claim generation verification at the time visit data is captured and reported. EVV platform capabilities should include the generation and submission of industry standard 837 claim transactions to the appropriate claims clearinghouse or payer for final adjudication and processing. This workflow is the only way to guarantee that EVV-mandated services are billed appropriately from the start. In addition, the tech stack on which an EVV solution is built should be robust, including dashboards that provide real-time snapshots of EVV compliance, predictive tools that help to identify social determinants of health, and the ability to flag anomalies before they result in medical emergencies.

Financial implications of non-compliance go beyond rejected payments

EVV non-compliance is a cost that no home care agency can afford. The financial consequences of an audit can be staggering — not just in the direct recoupment of funds but also in the ancillary costs, such as the time and resources required to rectify the situation. When an audit is conducted and its results become known, it can lead to customer skepticism and the swift dissipation of goodwill that a provider has diligently built over years of service. Trust forms the foundation of member care, and audits erode that trust, leaving members feeling unsafe. The perception of being deceived may disrupt their peace of mind and prompt them to seek a new agency.

Providers who face an investigation often discover the criticality of having an EVV safety net. It’s never too late to initiate this practice, though rebuilding a reputation following an audit or allegations does require a meticulous and time-consuming effort. Moving forward, there are actionable steps that can be taken. Providers should begin with a thorough assessment of their entire caregiver network and member care delivery to determine which resources are needed to eliminate gaps and unify the system. Any solutions implemented should offer robust reporting capabilities that enable the comparison and measurement of home care visit and claims data for compliance, mirroring the reporting standards and audit criteria of oversight bodies, such as health plans or state Medicaid agencies. These efforts effectively mitigate instances of fraud, waste, and abuse while upholding program integrity. EVV software should also empower providers to conduct routine internal quality assurance audits and implement approval rules that restrict certain tasks, such as visit edit approvals and physical timesheet uploads, to designated users like managers.

The best EVV vendors understand the home care industry inside and out. They offer solutions that are not just compliant but forward-thinking. An agency’s EVV platform should be a supportive partner in growth, not just a system that integrates into your network. And the best agencies are the ones that go beyond minimal compliance and choose to innovate, weaving EVV into the core operations of their business. Establishing that safety net helps to catch any claims that fall short, ensuring an agency’s forthrightness and precision in a landscape of strict regulations and exacting standards. Above all else, though, it puts members first. EVV establishes the rhythm that makes the difference between an agency that merely survives and one that truly shines, serving as the ultimate embodiment of a provider who exemplifies genuine, compassionate care.

By Lisa Dugan, Senior Director Government Relations and Channel Partnering at HHAeXchange

Author Bio

Through her oversight of HHAeXchange’s government relations program and focus on state Medicaid markets, Lisa Dugan has been contributing to and coordinating activities associated with the company’s national growth agenda for over three years. Her leadership with payer product marketing strategy in support of state Medicaid and health plan business development efforts has resulted in expanding the deployment of HHAeXchange’s purpose-built SaaS solutions for better homecare and better health.