Understanding Electronic Visit Verification (EVV) requirements: Are you ready?
To meet compliance requirements for electronic visit verification (EVV), providers will need to understand the high-level federal regulatory requirements. As well as, the state-specific rules, which can vary greatly and include requirements above the federal mandate. This article will explore the federal and state requirements for EVV and discuss the impacts for providers who don’t meet compliance.
Background on the federal requirements
Section 12006 of the 21st Century Cures Act (which was signed into law Dec. 16, 2016) added Section 1903(I) of the Social Security Act (SSA) which mandated that states implement the requirement for the use of an EVV system for all Medicaid-funded services requiring an in-home visit. As such, this included implementing an EVV system for personal care services (PCS) by Jan. 1, 2020, and home health care services (HHCS) by Jan. 1, 2023. If states are not compliant, they will see incremental reductions in Federal Medical Assistance Percentage (FMAP) matching of PCS and HHCS expenditures over the first five years of the requirement.
Good Faith Exemption (GFE)
There was a limited exception for the first year of the requirement if a state could demonstrate they made a good faith effort to comply and had encountered unavoidable delays in implementing an EVV system. As of July 2019, states could apply for this one-time Good Faith Exemption (GFE) and if approved, the FMAP reductions would not apply for calendar quarters in 2020 (for personal care services) or for calendar quarters in 2023 (for home health care services). This Cures Act provision on good faith exemptions does not authorize the Centers for Medicare and Medicaid Services (CMS) to delay the FMAP reductions for more than one year. All states, except Tennessee, have applied for the GFE.
The Cures Act is not limited to services explicitly titled PCS or HHCS in a state’s waiver or state plan. All services requiring an in-home visit that are included in claims under the home health category or personal care services category on the CMS-64 form are subject to the EVV requirement. In addition, services furnished under waivers or demonstration projects that meet the definition of a “home health service” or “personal care service” must meet the EVV requirement, even if they are bundled into a different service or furnished through a Medicaid managed care provider. In other words, if the service includes personal care services or home health services, even if it has a different name or includes other services, it is subject to EVV. Services provided to clients in a facility setting or services that do not require an in-home visit are not subject to the EVV requirement.
What must be verified electronically for in-home visits?
The Cures Act defines EVV as a system under which visits conducted as part of PCS and HHCS services are electronically verified with respect to the following six components of the visit:
- the type of service performed;
- the individual receiving the service;
- the date of the service;
- the location of service delivery;
- the individual providing the service; and
- the time the service begins and ends.
In addition, states are required to consult with providers of PCS and HHCS, seek stakeholder input, consider existing best practices and EVV systems in use in the state, ensure the opportunity for provider training, and ensure the EVV system is minimally burdensome and its use is compliant with the privacy and security requirements of the Health Insurance Portability and Accountability Act (HIPAA). Additionally, nothing in section 1903(l) of the SSA can be construed to limit provider selection, to constrain beneficiaries’ choice of caregiver, or to impede the way care is delivered.
The Cures Act affords great flexibility to states in model design and quality control measures.
State requirements: challenges for providers
As long as all federally mandated information is collected on an in-home visit by the provider, the state Medicaid agencies have a great deal of discretion in selecting the EVV system(s) that will most effectively meet their needs and significant autonomy in deciding how to gather and report EVV data. The states can also decide whether to include additional requirements and compliance rules. This can cause significant challenges for providers, especially those with multi-state operations who are seeing an absence of standardized data submission requirements across the states and by state-selected EVV vendors and aggregators (which can be different vendor organizations). In addition, this has been further compounded by payer-imposed directives. Since most states have given a great deal of autonomy to their state-contracted Medicaid managed care organizations (MCOs), which may have implemented additional requirements for providers.
This lack of standardization, both across and within states, has caused significant confusion and increased administrative burden to providers. In addition, the GFEs granted to states have caused confusion about which requirements providers will be held accountable for if any. The Good Faith Exemption only exempts states from FMAP reductions for one year. However, it does not exempt them from moving towards full implementation of EVV this year. Although states may have relief from penalties, they must meet the federal EVV mandate while also determining their own verification requirements, which may be more stringent than the federal rules require. Operationally, this means states will monitor provider verification efforts and enforce their state-specific implementation requirements. This includes defining the services that must be verified by EVV.
There are five major EVV system models with variances in state involvement and EVV management. The Cures Act requires that states have flexibility in the type of EVV model they implement. So long as their choice meets statutory requirements, including compliance with HIPAA privacy and security standards. CMS does not endorse any model. However, they note any model selected by the state must be able to generate the information required of EVV systems to verify the six components of a visit.
Preparedness checklist for agencies
With open and flexible models, providers need a strong partner to help implement changes in technology and ensure compliance. However, if you haven’t implemented a solution to meet the new EVV requirements, it’s not too late.
Here are steps to help bring your agency to compliance.
- Assign an internal leader to champion/own EVV.
- Know your state’s selected model(s).
- Identify where all state-posted stakeholder information, state EVV-related policies/procedures, and state-mandated EVV compliance requirements are available.
- So, ensure EVV implementation requirements are understood/confirmed with each state MCO your agency works with.
- Develop a structured workflow from field to back office for EVV requirements.
- Develop policies/procedures in your agency; include requirements/guidance for situations where technology failures or human errors may occur.
Education and training
- Make training mandatory for all applicable staff in both field and office.
- Also, cross-train staff in back-office workflow and requirements.
- Leverage training provided by your state Medicaid agencies, state-selected vendors, and MCOs.
- Include additional training on all agency policy/procedure and expectations.
- Structure training programs for new hires and on a re-occurring basis:
- At least quarterly is recommended to cover potential staff turnover and to ensure the capture of ongoing improvements to the state EVV program.
Troubleshooting and advocacy
- Engage with your state association for updates and advocacy needs.
- Engage with your state Medicaid agency, state MCOs, and state/MCO-selected vendors/aggregators.
- Ensure appropriate contacts are in place to escalate issues and needs as they arise.
To conclude, MatrixCare offers a comprehensive solution that can help you meet EVV compliance changes. Whichever technology you use, make sure the system can support your model. So, you can stay focused on providing care.
- gov EVV Website
- EVV Requirements in the 21st Century Cures Act: NASAUD Conference Workshop; CMS, August 2018
- 2018 Electronic Visit Verification Implications for States, Providers and Medicaid Participants, NASAUD
- FAQs: Cures Act for Electronic Visit Verification, Issued 5/16/18
- Electronic Visit Verification for Personal Care Services: Status of State Implementation; MACPAC The 21st Century Cures Act
The content in this presentation is for informational purposes only and is provided “as-is.” Information and views expressed herein may change without notice. So, we encourage you to seek, as appropriate, regulatory, and legal advice on any of the matters covered.