Medicare, Medicaid, and Insurance Payers

State Departments of Health and Payers can benefit greatly from having home care agencies use Electronic Visit Verification that is integrated with the agency’s back office EMR scheduling and billing system.  In these tight budgetary times, a standards-based approach to having home care agencies comply to using Electronic Visit Verification can help ensure the payer is paying only for the services authorized and actually performed.

Medicare, Medicaid and medical claim fraud compose the largest numbers of investigated insurance fraud cases in the United States. With nearly $60 billion dollars lost annually to fraud, Medicare and Medicaid fraud cases include questionable activities on the parts of patients and healthcare related providers.  Medical claim fraud depletes government funded healthcare, costs taxpayers billions, and drives up private insurance rates.

Fraud schemes which can be greatly minimized or even eliminated by using full featured EVV include:

  • Buddy punching

This involves the care recipient and visit staff conspiring together.  In non-standard EVV environments, such as agencies using manual paper-based approaches, the care recipient signs off on visits which never happened. Sometimes, these fraudulent actions are not intentional, as all too often home care agencies utilize a weekly activity log which is signed at the end of the week by the care recipient.   Having to accurately recall an entire week’s worth of visits is nearly impossible, so inaccurate visit information is often signed off on.

Home care  EMR software systems with EVV capabilities significantly minimize this problem.   Visits that are scheduled in the agency’s software system are marked as “complete” once the verified visit comes in, often in real-time in the case of using Telephony.

  • Rounding up actual visit times

In non-standard EVV environments, often times visit staff manually write down the time in/ time out of the visit on a paper note.  Sometimes, these are weekly notes.  This creates an opportunity for inaccurate visit time reporting.  Say for example, a caregiver arrived at the recipient’s home at 9:12AM for their visit and left at 9:52AM but they documented the visit was from 9:00 to 10:00, as it was scheduled.  The 1 hour visit truly only lasted for 40 minutes and based on payroll and billing rounding rules, this example could create fraudulent claims by putting an employee in an overtime situation, or billing for more than appropriate.

With EVV systems, actual visit times are automatically verified at the time the service is provided and they take any guess work or estimating away from the employee.  The result is exact service time recording, and by having the EVV capabilities integrated with the home care agency’s scheduling and billing system, payer rounding rules can be programmatically calculated to ensure proper claims are created based on these exact service times.

Payers stand to realize greater benefits from implementing policies which involve requiring home care agencies to utilize their choice of an EVV system instead of the payer mandating the use of a payer-managed and purchased EVV system.  There are enough benefits to home care agencies to utilize EVV that is integrated with their back office scheduling, billing, HR management, and client management system.  Often times home care agencies are performing services for multiple programs and payers, therefore it becomes unmanageable for these agencies to use different payer-mandated EVV systems for different payers and remain effective.

This workgroup of industry experts exists to provide information and an area for discussion that helps payers understand the types of EVV and associated benefits as they develop their strategies and set their standards.

Join the Conversation!  Comments in this section should be focused on the perspective of the Payer as it relates to EVV.

  1. March 21, 2011 at 4:12 pm

    This Healthcare IT News article highlights a reactive effort to help combat Medicaid fraud. While data mining is one method to help identify Medicaid fraud patterns, HHS and state Medicaid agencies could get in front of the problem with standard EVV language requirements and possible reimbursement ties.

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