Electronic Visit Verification (EVV) was established as law in 2016 under the 21st Century Cures Act to address fraud and abuse in home-based care delivery. The law provides federal guidelines, but individual states can determine which service codes are included. However, years after nationwide implementation, EVV still remains a burden for home care providers.

Simply put, EVV confirms the details of in-home visits. It holds caregivers accountable for their schedules, ensuring that their work is completed on time and in its entirety. Typically, caregivers work within a mobile app to conduct the EVV process. The app sends the necessary information from their devices to their agency’s home care software.

Six data points are captured at the point of care to verify the facts of a home care visit in real time.

Collecting this basic information in home care settings helps providers and states ensure that authorized care is provided and that caregivers deliver the proper care at the right time. When this verified visit data is collected and analyzed, states can use it to help identify and reduce Medicaid fraud, which drains resources from the system and hinders care delivery to those in need.

There was initial confusion because the act required states to implement EVV for at-home visits conducted by Medicaid personal care providers and home health agencies. However, each group had different go-live dates. Medicaid-funded personal care services were required to comply with EVV statutes by Jan. 1, 2020, and home health agencies by Jan. 1, 2023. However, delays and exemptions made compliance anything but simple.

Further, the federal government has passed legislation regarding EVV, but its implementation varies at the state level. States are categorized as “open” or “closed” models. Home health agencies have the freedom to choose their EVV provider in open states, while in closed states, they must work with a vendor selected by the state.

According to Matt Kroll, practice president of Assistive Care & Assistive Care State Programs at Bayada Home Health Care, despite challenges, Bayada has found that EVV helps prevent false claims.

“It allows us to monitor caregivers in real-time, verify service delivery, and allow for faster issue resolution,” he told Home Health Care News. “For example, if a check-in is late or a caregiver indicates that the client is showing signs of a larger issue, we can see that in real time and detect and prevent adverse events before they lead to a larger medical issue or hospitalization.”

Headquartered in Moorestown, New Jersey, Bayada provides in-home clinical care and support services in 21 states and five countries.

“We believe that we will be able to leverage some care documentation data points to help improve the quality of care we provide our clients and, over time, industry-wide data points may improve the industry as a whole,” Kroll said.

Kroll explained that Bayada supports efforts to prevent fraud, waste and abuse, with the caveat that overregulation can actually hurt the industry in some instances.

“We do feel that overburdensome requirements and unfunded mandates can deter agencies from providing Medicaid-based services, which is detrimental to those populations who already struggle to access the care they need to stay safely at home,” he said.

EVV still a pain point for providers

Because EVV varies by state, its challenges differ by market.

“EVV is still a pain point for providers for various reasons – and they vary by state,” Tim Nyberg, senior vice president of strategy at Sandata, told HHCN. “These can include variance in education from states to providers, the provider’s experience in onboarding and implementing EVV systems, how caregivers are educated on EVV, and whether they understand its purpose and benefits.”

Sandata, based in Port Washington, New York, provides agency management software, systems, and services to optimize billing and claims processing and streamline administrative processes.

“Additionally, some caregivers cite privacy issues in using their personal cell phones to clock in and out of shifts and having their location tracked,” Nyberg said. “Some clients and family members share those same concerns.”

Although all states have worked to implement effective EVV programs, some have needed help with clear and open communication regarding their policies, transparent enforcement timelines and timely responses to questions and concerns from the provider community.

“EVV continues to present challenges for providers primarily due to its complex integration into existing workflows,” John Atkinson, chief technology officer at AxisCare, told HHCN. “The additional effort required is not just about submitting claims, but also ensuring that EVV data is accurately collected and transmitted to the aggregator. This process requires meticulous attention to detail, often adding layers of administrative tasks to an already burdened system. Providers must balance maintaining the quality of care and adapting to new technological requirements, often leading to frustrations. While EVV aims to streamline and enhance transparency, the transition and implementation phase continues to be arduous.”

Founded in 2013, AxisCare is a full-service home care software company based in Waco, Texas.

“Bayada has made every effort to ensure that the transition to EVV compliance is as easy as possible for our caregivers and as least disruptive to client care as possible,” Kroll said. “However, pain points persist. Most notably, cost, lack of standardization across states, technology issues for caregivers and lack of cell service in rural areas.”

Providers who fail to comply with Medicaid rules risk not being paid for their work. Non-compliance with Medicaid rules and policies may also result in the provider’s inability to do business under the Medicaid program.

Apart from the stricter compliance issues, there are also significant downstream impacts. When caregivers fail to clock in at a client’s home, the home care agency cannot verify the services provided, especially in the case of a fall or hospitalization during or after a shift.

There is a continued lack of clarity regarding the consequences of non-compliance, according to Kroll.

States and payers each have a compliance threshold that needs to be met, and most – but not all – states have published this information. Non-compliance could result in payment penalties, loss of referrals, audits, and additional penalties and corrective action plans.

The future of EVV

States that have a burdensome EVV system run the risk of losing providers that may be otherwise interested in conducting business there.

“Looking ahead, the future of EVV will be marked by increasingly stringent standards and tighter tolerances,” Atkinson said. “We anticipate a future where the manual entry of EVV data will become largely unacceptable as states demand greater accuracy and efficiency.”

He emphasized the importance of proactively creating a culture of compliance and ensuring that staff are well-prepared to meet changing standards. This includes adopting technology and simplifying processes to enable smooth data transfer to aggregators.

“By staying ahead of these developments, providers can enhance operational efficiency and continue to meet regulatory requirements effectively,” Atkinson said. “Above all, EVV will enhance the accurate delivery of care to seniors, ensuring they receive the attention and services they need when needed.”

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The budget makes major changes to New York’s Consumer Directed Personal Assistance Program (CDPAP).

Under New York’s CDPAP, individuals seeking care are allowed to hire a caregiver of their own choosing. This often means informal caregivers. These caregivers are paid for their services through the program.

The most notable change the budget makes to CDPAP is that it will designate one statewide fiscal intermediary to oversee the program.

Some of New York’s home-based care providers — AccentCare is one example — serve as fiscal intermediaries (FI).

“Our providers really feel like the state is trying to dig a hole with a grenade,” Kevin Wade, a vice president at Sandata, told Home Health Care News. “The state takes the perspective that there’s significant fraud, waste and abuse within CDPAP. They feel that by moving to one, singular FI, they can reach $200 million worth of savings. A change like this adds an additional layer of complexity to an already complex system.”

Sandata is a technology company and an electronic visit verification provider. It works with states, home-based care providers and MCOs.

Wade noted that there were likely other steps the state could’ve taken to help reduce fraud, waste and abuse that would not have upended the current system.

“There are ways to monitor and oversee programs without necessarily altering or transforming the way that care is delivered,” he said.

There are also many questions about how having one statewide FI would work in practice, according to Wade.

“There’s a lot that’s still to be figured out with one singular FI, in terms of how many subcontractors will be allowed within a given area,” he said. “We know that there’s going to be at least one subcontracted FI per rate setting region, so there’s four within New York State. But past that, it’s not known. We don’t know who this fiscal intermediary would be.”

Wade also pointed out that moving from hundreds of FIs to one could impact care, as many of the providers that serve in this role are entrenched in the communities they operate in.

Aside from changes to CDPAP, the budget included a minimum wage increase for home care workers, and Medicaid rate increases for hospitals, nursing homes and assisted living communities.

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In 2024, providers will need to prepare for a very different environment that does not include these financial buffers.

“We’ve had success in many states, over the last couple of years,” Dave Totaro, chief government affairs officer at Bayada Home Health Care, recently said during a Home Health Care News webinar. “Notably, [we saw] big increases in states like Missouri and Delaware, which hadn’t seen increases for over maybe one or two decades. Given the fact that these funds are drying up, on the federal level, [we expect that] states are going to begin to pull back.”

There might even be enough of a discrepancy between funding in different states that even large companies will consider leaving markets that make it difficult for providers to deliver care services.

Many providers are already having to deny upwards of 65% to 75% of their referrals, according to Totaro.

“Higher reimbursement states, like Massachusetts, Delaware, even New Jersey might be a bit better off, but eventually, if you can’t provide care because you’re losing money, you can’t provide quality care,” he said. “We’ll probably have to make those hard decisions. No health care provider ever wants to leave patients without health care.”

Lower reimbursement states such as Mississippi, and others, may see providers leave these markets.

Emmet O’Gara, CEO of Sandata, emphasized that most providers will try to face the unique challenges of each state before deciding to stop operating in a specific market.

“I think for the most part, we’ve seen folks positioning themselves to be as successful in the state they serve, as they can, versus wholesale, ‘I’m out of here,’” he said during the webinar. “Regulation can alter that path. Most of the folks that we work with are in this business because they are mission driven, economic realities, of course, can challenge that.”

Though some providers might be slow to exit a state entirely, this doesn’t mean that there won’t be some kind of fallout.

For example, a company may decide that they will keep operating in a state, but choose to pull out specific pockets in that market, Care Advantage CEO Tim Hanold said during the webinar.

“It might not be wholesale — folks moving out of a state — but its rural communities, it’s deep cultural pockets,” he said. “Areas without scale that don’t have density, and don’t have favorable economics. Those are the ones that will suffer.”

Further compounding challenges is Medicaid redetermination, which is happening in many states across the country. Totaro thinks this will make things even tougher for providers.

Even with rumors of additional funding, Totaro believes that it’s unlikely that this will actually result in more money being distributed.

“We do hear on the Hill that there is some talk, particularly among Democrats, for some additional funding in 2024, along the lines of the American Rescue Plan, but in reality they’re just generating headlines, and maybe some election year talking points for themselves,” he said. “I doubt we’re going to see any kind of reimbursement funding increases happen from the federal government.”

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