Evidence record
Medicaid Program: Provider Compliance With the Electronic Visit Verification Program
- Jurisdiction
- New York
- Publishing agency
- Office of the New York State Comptroller, Division of State Government Accountability
- Publication date
- November 13, 2024
- Source record
- Original document linked
Findings
6
Recommendations
11
Overall 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.
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.
Findings (6)
Each finding has a stable link.
- F-863
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.
- F-864
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.
- F-865
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.
- F-866
Some PC payments were for durations under 8 minutes and not billable; 65,626 PC and HHC services occurred while recipients were hospitalized.
- F-867
OMIG did not ensure providers meeting VO pre-claim review requirements actually obtained a VO; VO requirement ended January 2024.
- F-868
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)
- R-763
Update the EVV Manual to include all allowed procedure/modifier code combinations and address oversights in codes.
Related finding F-868 - R-764
Improve oversight and monitoring of EVV data submissions, including states to ensure service locations and service dates are accurate.
Related finding F-865 - R-765
Improve monitoring of EVV submission error message logs and take corrective actions to reduce rejected records.
Related finding F-868 - R-766
Ensure EVV API keys remain active and monitored to prevent submission gaps.
Related finding F-865 - R-767
Develop and implement procedures to utilize all EVV reports as monitoring tools, including identifying variances between EVV records and claims.
Related finding F-865 - R-768
Develop controls to identify manual adjustments made to EVV records before submission to the Aggregator.
Related finding F-865 - R-769
Review and recover payments for overlapping time frames and hospital-stay payments; improve controls for 8-minute minimum and hospitalization rules.
Related finding F-866 - R-770
Improve controls to identify and prevent payments for services with overlapping time frames and to recover improper payments.
Related finding F-866 - R-760
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.
Related finding F-863 - R-761
Establish an EVV compliance program that will allow for the denial of improper claims and recoupment of improper payments.
Related finding F-865 - R-762
Verify the residence status of live-in caregivers to ensure EVV exemptions are valid.