Program Integrity solutions
Medicaid-funded homecare is uniquely vulnerable to fraud, waste, and abuse (FWA). To address these FWA risks, states and payers are looking to go beyond Electronic Visit Verification (EVV). That’s where HHAeXchange comes in. We deliver a smarter, data-driven solution to strengthen program integrity.
HHAeXchange’s Program Integrity tools use EVV data as a foundation to uncover issues, resolve conflicts, and recover lost funds. Our solution empowers payers, providers, and state agencies with actionable insights to help surface suspicious activity faster—supporting better decisions, streamlined investigations, and reduced costs.
In fiscal year 2024, Centers for Medicare & Medicaid Services (CMS) reported an estimated
$31.1 billion in improper Medicaid payments
with overall estimates that Medicaid fraud could potentially be $30-50 billion.
Centers for Medicare & Medicaid Services (CMS) Fact Sheet, November 2024
HHAeXchange has been an excellent partner to the District’s Medicaid program. HHAeXchange’s solutions-oriented approach and readiness to develop tailored data solutions have been instrumental in opening the door for new avenues to root out fraud, waste, and abuse.
DC Program Integrity Office
By pulling data from HHAeXchange and alternative EVV systems, our platform delivers a real-time view into provider performance and potential fraud cases before payments are released. The result? Faster intervention, smarter oversight, and stronger program sustainability.
This sample FWA dashboard shows how our solution brings suspicious activities to your attention sooner.
HHAeXchange’s monthly FWA Risk Scorecard uses weighted indicators—such as visit conflicts, manual edits, and authorization violations—to rank providers by risk level. This helps agencies focus investigative resources where they matter most.
Replaces manual tasks with real-time coordination among stakeholders.
Centralizes EVV and claims data for easy analysis and compliance tracking.
Flags billing conflicts before claim submission, ensuring payment only for verified services.
Combines EVV and monitoring to enhance care quality and improve health outcomes.
Program integrity in this context refers to protecting Medicaid-funded homecare services from fraud, waste, and abuse (FWA). It involves making sure that visits occur, services are delivered and documented correctly, authorizations are followed, and billing matches service delivery.
EVV (Electronic Visit Verification) data is used as the foundation for identifying irregularities — e.g. overlapping visits, visits outside of clock-in geofence, or services performed outside authorized schedules. This data, combined with other sources (claims, authorizations), is used to flag anomalies for review.
It’s a composite scoring system that takes multiple indicators (such as visit conflicts, authorization violations, GPS/geofence anomalies, manual edits) and weights them to estimate which providers are most likely to have improper practices. This helps target oversight or audits to the highest risk providers.
EVV is necessary but not always sufficient. Program integrity is improved when EVV data is combined with claims data, authorizations, provider screening (for example cross-checking exclusion lists), and monitoring tools that detect under- or over-utilization of authorized services. HHAeXchange’s solution does use multiple data sources.
Yes—the Platform supports ingesting data from “in-house or alternative EVV systems” so that the dashboards and FWA-detection tools can still see a consolidated view.
Reach out to learn more about how HHAeXchange helps states preserve program integrity by targeting fraud, waste, and abuse.
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