Since the passage of the 21st Century Cures Act in December 2016, the entire homecare ecosystem has been gearing up to comply with the new electronic visit verification (EVV) requirements. For Medicaid-funded personal care services, states must now require the use of EVV to avoid financial penalties. By January 1, 2023, this will include home health care services.

However, for most states, full EVV compliance has just begun. In response to stakeholder feedback and the unexpected complications of COVID-19, the Centers for Medicare and Medicaid Services (CMS) allowed states to file good faith effort (GFE) exemptions, extending the deadline for compliance to January 2021. With the exception of Tennessee, all states applied for a GFE exemption and received approval from CMS. While there was clearly a universal need for more time, the GFE applications reflected a broad range of delays in implementing EVV – from managing technology issues to accommodating self-directed services.

Given these initial obstacles, what’s the status of EVV in 2021? And how can the industry shift from an implementation mindset to one of continuous improvement?

To answer these pressing questions, we spoke to three industry executives. Christie Watson, Vice President and General Manager of Payer Solutions at HHAeXchange, works with both national and regional payers on EVV implementations. Stephen Vaccaro, President at HHAeXchange, has more than a decade experience working with payers and providers on EVV, workflow efficiencies, and value-based care. Mollie Murphy is the Co-Founder of Annkissam (an HHAeXchange company) and is a nationally recognized expert on Financial Management Services (FMS) in self-direction. She provides a valuable perspective on how EVV and self-direction can work together.

What do you see as positives in EVV implementation so far?

“From the beginning, there’s been a lot of flexibility,” says Christie Watson, “States have had a lot of latitude in designing their program to meet the CURES Act requirements. They were able to determine who would be responsible for managing the EVV system and which technologies to use.”

She added that states have taken the requirement for stakeholder input seriously and programs have the flexibility to address their concerns. For example, provider feedback in certain states has led to some positive changes like more non-English language options and privacy safeguards given the GPS technology used for verifying visit locations.

“The EVV requirements in the Cures Act were never meant to be punitive,” Watson says. “It’s a positive funding opportunity to help payers and providers achieve more streamlined processes, reduce fraud, and deliver better patient care. Flexibility was built into the guidance from CMS, so states could implement EVV in a way that worked for them.”

What do you see as the biggest obstacle in EVV implementation?

“Aside from the obvious delays due to COVID-19, flexibility can also be a double-edged sword,” says Watson. “The lack of CMS compliance specifications for billing and authorizations, for example, led to varying interpretations by each state. That means for national or regional homecare providers, data requirements can be quite different across multiple states. And as you can imagine, this is a major administrative challenge. In some cases, the EVV tools and who purchases them could be different too.”

“Plus, if managed care organizations (MCOs) and individual states have different data elements, it makes it more difficult to share and analyze the data,” continued Watson. “That was meant to be one of the benefits of EVV – more transparency and access to data.”

Is there a push for more consistency going forward?

“Yes, that is definitely the question everyone is asking,” says Watson. “Will there be a national EVV interoperability standard? While it’s more at the discussion level right now, there’s a clear need for more standardization. We’d like to see, at a minimum, electronic data interchange (EDI) visit data specifications.”

She added that consistency in other areas would be valuable, such as the reasons for manual visits and missed visits. Moving to an application programming interface (API) requirement for the exchange of visit data would also make it easier to share and aggregate data.

“Organizations like the National Electronic Visit Verification Association (NEVVA) advocate a third party to lead the charge in this area so each state has an equal voice in the development of standards, Watson says.”

How can payers and providers address these issues in the meantime?  

“From a payer perspective, make sure you communicate your policies clearly,” says Watson. “Give written direction when there are gray areas, like when services start in the home and end in the community, or when there’s a live-in caregiver. Technology should reinforce these policies and make it easy for providers to comply.”

Vaccaro added, “For providers, be sure to ask questions often and early, so your claims aren’t denied. Collect the data, evolve your workflow, look at your technology solutions, and make adjustments before you’re at risk for any penalty. This is critically important if you provide services across several states.”

How are states with self-direction programs managing the EVV requirements?

“This has certainly been a challenge, given that most EVV solutions were built with traditional homecare models in mind,” says Mollie Murphy. “In self-direction, the participant acts as the employer. If an EVV system requires the participant to input a schedule in advance or removes their ability to adjust time recorded, this takes away their autonomy as an employer – and ultimately undermines the tenets of self-direction.”

She added that using an EVV system with a geo-fence (virtual parameter) also poses a problem. “Self-directing participants are active members of their community. It would be unreasonable for them to mark an ‘exception’ in the system every time they leave their home. A better solution is capturing the location of the services, rather than making ‘home’ the default.”

How can you ensure the chosen EVV solution doesn’t erode the principles of self-direction?

“The best EVV systems will fit into an FMS entity’s workflows, not attempt to replicate or replace them,” says Murphy.

She recommends thinking through self-direction use cases and then testing them out fully in the EVV solution. For example, what would happen if:

  • Workers are paid varying rates by the same participant for different services.
  • The same worker is paid different rates by different participants.
  • A single worker works for multiple participants, but neither participant has access to the other’s data.
  • A single worker provides service to multiple participants simultaneously.

“These are common self-direction scenarios and your EVV system should be able to accommodate them,” Murphy says. “Be careful of policies where workers are not paid for time worked because of EVV compliance. Liability for non-payment of wages can be steep and invite rights of action.”

How are EVV systems handling live-in caregivers?

“With the growth in self-direction, particularly during the pandemic, there’s been a surge in live-in caregivers. However, states are permitted to exempt live-in caregivers from EVV requirements,” says Watson. “Many states are using a signed attestation to indicate the exemption, but unfortunately, this doesn’t help with the adjudication process. I’ve seen some discussions about using a service code modifier, so the exemption shows up during the workflow.”

What do you see as keys to success as we move past the initial implementation?

“In order for this whole system to work, caregivers need to have the right training and support,” says Vaccaro. “We can’t underestimate the importance of getting caregivers prepared and on board with the process. This should be a high priority for agencies, and payers need to emphasize the consequences of noncompliance.”

Watson added, “My recommendation is to communicate, communicate, communicate. The more everyone is talking, the sooner we can iron out these wrinkles. We should probably expect more changes as this process is streamlined in the next few years, so it’s best to be an active stakeholder, speaking up with your ideas for improvement.”

So, what’s ahead? Now that agencies across the U.S. have begun successfully implementing EVV, we expect the focus to shift toward collaborative improvements that make EVV easier and more effective for all stakeholders. As challenges are addressed, we look forward to seeing the benefits of this system, both in financial and quality of care measures. The Congressional Budget Office (CBO) anticipates that EVV will save states $290 million over a ten-year period by reducing inefficiencies and fraud. Most importantly, this new transparency and access to data will improve quality of care by confirming appropriate service delivery, identifying gaps in care, and preventing adverse health events.

Learn more about how HHAeXchange helps both payers and providers exceed the 21st Century CURES Act requirements with our advanced EVV software. Plus, see how our self-direction solution with Annkissam (an HHAeXchange company) ensures the choice and control inherent in self-direction in the least-restrictive way for participants.