Claims integrity is vital to the success of organizations billing for services under Medicaid and Medicare. With the many federal and state mandates each year, it can be difficult for billing staff to keep up. When this happens, the organization is at risk for being non-compliant with regulations. A non-compliant organization can suffer many fates. Regulators can take money back, penalties can be leveraged, the ability to perform certain services can be revoked, and there is a potential to lose provider contracting. At the end of the day, non-compliance can shut an agency down.

One current example we can easily discuss is how Electronic Visit Verification (EVV) can put your agency out of compliance quickly. The 21st Century Cures Act requires states to mandate the use of EVV for certain home and community-based services. States have worked hard to try and keep up with the guidance given to them, but the home care providers tend to be the ones paying the price. Whether the agency is using their own EVV system, or the system the state provided, there is a lot to look at to make sure the agency is EVV compliant.

When looking at EVV claims, you have to consider the state’s policies and rules related to EVV. Did you submit your claims before you had a valid EVV visit in the system? Are you billing the right service code? Does your vendor have the right cross-walk built in to match the states EVV system? Is your vendor submitting the visits to the states EVV system according to the states rules? Did your vendor configure the system correctly according to the technical specifications? If your visits are failing the EVV claims validation, there are many reasons this could be happening. If you are using your own EVV vendor, those reasons are exponentially higher.

For providers in states where claims are not yet denying due to EVV, the providers may not know they are out of compliance. You may be surprised how many home care providers have no idea they are out of compliance because there has been no impact to cash flow. If the state or managed care organization is still paying EVV related claims, this does not mean the organization is compliant. It means the agency is in a grace period to get compliant. Now is the chance to position the agency for success.

Another thing to know, is that even if the claims are EVV compliant, it does not necessarily mean the Payers’ systems are configured right. This means the agency is doing what is expected, but it looks like they are not. In my experience, there have been several payers who did not know there was an issue on their side until we reported it to them.

At IYC, we have skilled consultants who can help ensure your organization is compliant. Our consultants have many years’ experience working for state agencies to monitor compliance, and they have brought that skill to the private sector. We have already been working with providers across the country to bring their EVV visits into compliance successfully. Why not let us help you do the same?