Monitors could cut fraud in Medicaid home care

With little fanfare, Congress in December 2016 passed a law that has the potential to significantly reduce health care fraud in North Carolina and across the country.

A section of the 21st Century Cures Act mandates the use of “electronic visit verification” (EVV) systems for all providers of personal care and home health care services when billing through Medicaid. This verification system is being implemented for one reason: to reduce fraud in the home health care industry by verifying home care services billed are for actual visits made.

Although the visit verification rules are federally mandated, state Medicaid departments, including North Carolina’s, have been charged with deciding how EVV procedures are rolled out in their states, and with overseeing compliance among home care providers. The deadline for North Carolina and other state Medicaid departments and home care agencies to implement EVV programs is Jan. 1, 2019.

The N.C. Department of Health and Human Services’ Medicaid agency spends about $821 million annually on home health care and personal care services, according to Kaiser Family Foundation figures. Based on the results of EVV implementations in other states, where gross savings range between 10 and 20 percent, North Carolina can conservatively expect to eliminate between $82 million and $160 million a year in Medicaid payments.

The use of EVV systems is not new. Several states, including New York, have required home health and personal care agencies to use EVV systems for a number of years. In fact, New York has required its home care agencies to use electronic visit verification systems for the last 30 years, and its Department of Health Services estimates savings to be in the range of $1 billion over that time. Other states have piloted these systems, with strong results. The Florida Medicaid and Public Assistance Strike Force Report detailed $19 million in savings for Miami-Dade County in one year; and an EVV implementation in Illinois led to 200 Inspector General investigations and the recovery of more 1,200 hours of overpayment.

In North Carolina just last year, three owners of a North Carolina-based home health care agency were sentenced to 20 years in prison and ordered to pay almost $6 million in restitution.

Even among well-intentioned home care agencies, the use of verification systems has resulted in a small reduction in Medicaid billing, as the system catches billing mistakes and the health aide who misreports a home visit that actually didn’t occur.

The goal is to prevent fraud but at the same time not unduly burden the state’s nearly 800 hardworking and honest home health and personal care agencies. With this in mind, the state’s Department of Health and Human Services has been proactively discussing how the new EVV system might be executed with several organizations, including home care agencies and the association that represents them, the Association for Home & Hospice Care of North Carolina.

We at Sandata believe electronic visit verification is good for taxpayers, good for patients and good for home care agencies. We advocate for an “open model,” in which the state’s Medicaid office chooses or recommends one technology vendor’s EVV solution while allowing home care agencies to keep their existing systems, or to choose a new system that best suits their operation. The state would then establish the technology requirements and configuration, rules and policies regarding the program in order to best monitor for compliance and billing. A significant percentage of N.C. home care agencies already use some form of electronic visit verification, and they should not be penalized for proactively managing their businesses in advance of the federal mandate.

Other models call for the state to force each home care provider to use software purchased by the Medicaid office, leaving agencies to adapt their operational processes around this new software. Another model calls for managed care organizations to dictate the EVV software required by agencies, forcing agencies to use multiple solutions, depending on the MCO’s choice.

We believe the open model offers the best of both worlds to home care agencies and North Carolina’s Medicaid division. Home care providers are offered the flexibility to use whatever EVV solution they prefer, but all claims are funneled through an aggregator system where standardized business rules are applied to ensure visits are properly verified, and ultimately paid, providing comprehensive oversight to the entire program.

Tom Underwood is the CEO of Sandata Technologies, a Long Island-based provider of electronic visit verification and home care management software solutions.

Go to Source