Medicaid Program: Provider Compliance With the Electronic Visit Verification Program
Learn how the AI-generated research projects were createdOverall Conclusion
DOH’s EVV program showed significant control weaknesses and data quality issues, with large volumes of Medicaid payments made without matching EVV records and with low EVV-claim match rates (56% for PC and 11% for HHC). The VO pre-claim review requirement ended in January 2024, and DOH planned to offset this with reliance on EVV, prompting stronger calls for improved oversight, data quality, and a formal compliance program to deny or recoup improper payments.
Source Document
Audit Scope
Examined paid Personal Care (PC) services with service dates from January 2021 through March 2023 and paid Home Health Care (HHC) services with service dates from January 2023 through March 2023. Data from the Medicaid Data Warehouse (MDW) and eMedNY; included judgmental samples of seven providers and two EVV vendors; data through June 2023 and October 2023 used for cross-checks.
Key Findings Summary
Medicaid paid $14.5 billion for 82 million personal care services and $97.6 million for over 400,000 home health care services that did not have matching EVV records.
PC and HHC services with no EVV matching records had match rates of 56% for PC and 11% for HHC, far below the DOH goal of over 90% match rate.
DOH did not establish adequate internal controls to ensure EVV requirements were followed; did not use all EVV records to match with claims, did not consistently monitor provider non-compliance, and did not take administrative actions.
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AI-Assisted
AI Scope Summary
For future Medicaid EVV audits, build on these findings to focus on strengthening enforcement and pre-claim reviews (including the VO program), ensuring timely and complete EVV data submission, validating data quality (locations, dates, durations), and establishing consistent data identifiers to enable robust matching and recovery of improper payments.
AI-Generated Insight
The audit exposes substantial gaps in EVV data integrity, matching logic, and governance. Despite a formal EVV framework, DOH and OMIG had limited enforcement mechanisms (as the VO pre-claim reviews ended) and did not consistently monitor non-compliance or error trends, leading to billions in payments lacking EVV support. Implementing recommended actions—such as updating the EVV Manual, establishing a formal denial/recoupment process, enhancing data validation, and standardizing identifiers—could greatly improve fraud prevention and program integrity, provided these changes are timely and effectively integrated across vendors and claims systems.
Audit Objectives
To determine whether Medicaid made payments for personal care and home health care services that were not supported by required electronic visit verification records.
Audit Findings (6)
Medicaid paid $14.5 billion for 82 million personal care services and $97.6 million for over 400,000 home health care services that did not have matching EVV records.
PC and HHC services with no EVV matching records had match rates of 56% for PC and 11% for HHC, far below the DOH goal of over 90% match rate.
DOH did not establish adequate internal controls to ensure EVV requirements were followed; did not use all EVV records to match with claims, did not consistently monitor provider non-compliance, and did not take administrative actions.
Some PC payments were for durations under 8 minutes and not billable; 65,626 PC and HHC services occurred while recipients were hospitalized.
OMIG did not ensure providers meeting VO pre-claim review requirements actually obtained a VO; VO requirement ended January 2024.
EVV data quality issues: records not copied from EVV History Table to EVV Crosswalk Table; code/modifier mismatches; large numbers of EVV records with invalid or non-listed code combinations.
Recommendations (11)
Update the EVV Manual to include all allowed procedure/modifier code combinations and address oversights in codes.
Improve oversight and monitoring of EVV data submissions, including states to ensure service locations and service dates are accurate.
Improve monitoring of EVV submission error message logs and take corrective actions to reduce rejected records.
Ensure EVV API keys remain active and monitored to prevent submission gaps.
Develop and implement procedures to utilize all EVV reports as monitoring tools, including identifying variances between EVV records and claims.
Develop controls to identify manual adjustments made to EVV records before submission to the Aggregator.
Review and recover payments for overlapping time frames and hospital-stay payments; improve controls for 8-minute minimum and hospitalization rules.
Improve controls to identify and prevent payments for services with overlapping time frames and to recover improper payments.
Review the $14.5 billion in PC and $97.6 million in HHC paid services with no matching EVV records and ensure proper EVV support.
Establish an EVV compliance program that will allow for the denial of improper claims and recoupment of improper payments.
Verify the residence status of live-in caregivers to ensure EVV exemptions are valid.