🇺🇸United States

Fraudulent or Abusive Billing Uncovered Through EVV Audits and Investigations

3 verified sources

Definition

Federal oversight documents state that EVV was explicitly developed to address weaknesses in personal care services that contributed to improper payments and significant fraud, such as billing for visits not rendered or inflated hours. As EVV data becomes available, OIG and state Medicaid program integrity units use it to identify and pursue fraudulent patterns, leading to recoupments and, in some cases, civil or criminal penalties for agencies and individuals.

Key Findings

  • Financial Impact: Fraud cases in personal care and home health routinely involve hundreds of thousands to millions of dollars in improper claims over multiple years; when EVV data is used to prove overbilling, providers can face full recoupment plus penalties, effectively wiping out years of revenue for the implicated programs.
  • Frequency: Monthly
  • Root Cause: Weak supervision of field caregivers, reliance on self-reported paper timesheets, and fragmented oversight in services for the elderly and disabled created opportunities for systematic overbilling; EVV data now exposes these schemes and drives aggressive recovery actions by payers and regulators.[2][3][7]

Why This Matters

This pain point represents a significant opportunity for B2B solutions targeting Services for the Elderly and Disabled.

Affected Stakeholders

Agency owners and executives, Billing managers, Frontline caregivers engaged in falsifying visits, Compliance and legal staff, State Medicaid fraud control units

Deep Analysis (Premium)

Financial Impact

$100,000 - $1,000,000 annually per AAA from undetected improper payments; regulatory fines from state if fraud is discovered; loss of Medicaid contract if non-compliance is flagged; liability for federal False Claims Act. • $100,000 - $1,500,000 per LTCI carrier annually from fraudulent claims; claims recoupment and investigation labor; subrogation case costs; coverage disputes with beneficiaries. • $100K-$1.5M+ per claimant recoupment; policy credibility damage if widespread

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Current Workarounds

Beneficiaries/EORs track caregiver hours manually; verbal agreements; WhatsApp timekeeping; delayed EVV entry; manual reconciliation when disputes arise • Billing Specialist works with AAA program coordinator to manually review and negotiate claim adjustments; uses spreadsheets to track disputed amounts • Billing Specialists manually compare EVV reports to submitted claims; adjust records retrospectively; negotiate with state post-audit

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Methodology & Sources

Data collected via OSINT from regulatory filings, industry audits, and verified case studies.

Evidence Sources:

Related Business Risks

Medicaid Claim Denials and Non-Payment Due to EVV Data Errors

Commonly reported in trade literature as 2–10% of billable hours at risk during EVV rollout and ongoing for agencies that do not tightly manage EVV exceptions; for a $5M Medicaid personal care provider, this equates to ~$100,000–$500,000 per year in preventable lost revenue.

Increased Administrative and IT Overhead to Maintain EVV Compliance

$50,000–$300,000 per year in extra compliance headcount, IT support, training, and vendor fees for a mid-sized multi-million-dollar Medicaid home care provider, based on typical staffing patterns described in industry EVV implementation guides.

Cost of Poor Visit Data Quality Leading to Rework and Corrective Actions

Commonly manifests as 5–15 hours per week of back-office rework for every 50–100 field staff, translating to roughly $1,000–$5,000 per month in labor for a mid-sized provider, plus the revenue impact of delayed or partially paid claims.

Slower Time-to-Cash from EVV-Linked Claim Holds and Audits

Extended days-sales-outstanding (DSO) by 15–30 days during and after EVV implementation is commonly reported by agencies in industry forums; for a provider billing $400,000 per month, that locks up $200,000–$400,000 in working capital and can force reliance on credit lines.

Lost Care Capacity from EVV-Driven Administrative Burden on Field Staff

If aides lose even 10 minutes per shift to EVV-related tasks across 100 visits per day, that is ~1,000 minutes (~16.7 hours) of lost capacity daily; at $25 fully loaded cost per care hour, this is roughly $10,000 per month in capacity loss.

State and Federal EVV Non-Compliance Penalties and Funding Reductions

At the state level, FMAP reductions of up to 1% represent tens of millions of dollars in lost federal funds annually in large Medicaid programs; providers then experience recurring financial impact through underpayments, clawbacks, and exclusion from networks when they are found out of compliance.

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