When a state flips the switch on Electronic Visit Verification (EVV) enforcement, the effects on Medicaid home care providers can be immediate and costly.
Before we dive in, let’s cover a few key terms.
Background: Key Terms to Know
EVV (Electronic Visit Verification)
A system used to electronically verify that home care services were delivered. It typically tracks the who, what, when, and where of each visit using caregiver check-in/check-out times, GPS, and service codes.
Hard EVV Edits
Once a state enforces hard edits, claims will be automatically denied if the shift does not match the EVV data exactly. This includes mismatches in time, service code, or visit verification status.
Soft EVV Edits
Before enforcement kicks in, some states use “soft edits” to flag issues without denying payment. Providers may still be paid, but with warnings or follow-up audits.
MCO (Managed Care Organization)
An insurance plan that manages Medicaid services for enrolled clients. States contract with multiple MCOs to handle different populations or regions.
MCO Transition
When a state changes which MCOs are active (or when MCOs change policies, merge, or exit the market) it can affect client coverage, authorizations, billing processes, and provider contracts.
What Does It Mean When a State “Turns On” EVV?
When a state “turns on” EVV, it typically means the state is moving from optional or soft enforcement to mandatory, claims-enforced EVV requirements.
Specifically, this involves:
- Hard EVV Edits: The state’s Medicaid system starts rejecting any claim that does not have a matching, verified EVV record. That means if a caregiver forgets to clock in, clocks in late, enters the wrong location, or if the EVV system doesn’t sync properly, the shift will be denied automatically with no exceptions.
- Full EVV Compliance: All providers delivering EVV-eligible services must submit visit data through an approved EVV system. The data must match the claim exactly: on times, dates, caregiver IDs, service types, and location (GPS or address-based).
- Claims Validation Using EVV: The state Medicaid agency cross-checks each claim against EVV records before payment is approved. If the visit data is missing, incomplete, or mismatched, the claim will not be paid.
This shift often happens in phases, with increasing enforcement over time, but once hard edits are in place, the financial impact is immediate for providers who aren’t fully EVV-compliant.
Examples of EVV and MCO Disruption
Several states have made major changes recently. The details vary, but the types of operational impact to expect are consistent.
Indiana
- Enforced hard EVV edits in 2023
- Transitioned to a full MCO model in 2024, requiring new plan contracts and billing changes
Nebraska
- Requires 100% EVV compliance, where providers cannot even bill manually edited shifts
Arizona
- Currently changing MCOs and EVV vendors, leading to instability in plan coverage and system requirements
Tennessee
- Moving to a new EVV vendor, requiring agencies to adapt workflows and retrain caregivers
Wisconsin
- MCO acquisitions are altering which providers can participate and which clients are eligible for home care through specific plans
What Hard EVV Edits Mean for Providers
Once a state turns on hard edits:
- Claims are denied for any shift that doesn’t exactly match the EVV record.
- Manual fixes increase, raising staff workload and audit risk.
- State and MCO scrutiny grows, with tighter oversight of visit accuracy and billing.
MCO Transitions = Payer Instability
When MCOs are added, removed, or changed:
- Authorizations may be delayed or lost in the transition.
- Clients may be forced to switch plans—sometimes without warning.
- Some MCOs may stop covering home care, forcing clients and agencies to find alternatives quickly.
How to Protect Your Agency
Here’s how to avoid denials and disruptions during EVV or MCO changes:
- Audit your systems to ensure clean data flow across EVV, scheduling, and billing.
- Test EVV integrations and resolve sync issues before they affect claims.
- Train caregivers on proper clock-in/out behavior, GPS usage, and error prevention.
- Train schedulers to review authorizations and adjust for travel time.
- Run regular eligibility checks, especially if clients recently changed plans.
- Monitor updates from your state Medicaid agency and active MCOs.
- If a client’s MCO is dropping home care, inform them and help them switch if other plans are available.
Bottom Line
When a state activates hard EVV enforcement or reorganizes its MCO landscape, providers need to act fast. Claims, revenue, and client care all depend on your ability to adjust quickly and stay compliant.
Paradigm can help with all of the above. We take care of the entire claims management process from start to finish and act like a highly-trained in-house billing department on your behalf. Above all, we work to keep you compliant and your business future-proof.
To learn more, request a demo below.
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