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
OMIG did not ensure providers meeting VO pre-claim review requirements actually obtained a VO; VO requirement ended January 2024.
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.
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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.