🇺🇸United States

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

5 verified sources

Definition

Home- and community-based providers for the elderly and disabled frequently lose revenue when visits are not captured correctly in EVV (missing clock-in/out, wrong service code, GPS/location mismatches), leading to claim denials or delayed payments by state Medicaid programs. Industry EVV vendors and provider associations report that agencies move from paper timesheets to EVV largely to stop losing billable hours and prevent claims from being rejected for non-compliant or incomplete data.

Key Findings

  • Financial Impact: 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.
  • Frequency: Daily
  • Root Cause: Complex state-specific EVV rules under the 21st Century Cures Act require that each visit capture who, what, where, and when, and states tie Medicaid payment to clean EVV records; when staff miss punches, use workarounds, or systems fail to transmit clean data to the state aggregator, visits become non-billable or are denied.[1][2][3][4][5][8]

Why This Matters

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

Affected Stakeholders

Home care agency owners, Revenue cycle managers, Billing specialists, Schedulers, Field caregivers (aides, personal care assistants)

Deep Analysis (Premium)

Financial Impact

$100,000-$300,000 per year in lost billable hours and claim delays • $100,000-$400,000 per year in denied claims due to schedule-EVV mismatches • $100,000-$500,000 per year in claim denials if corrections are not made in time

Unlock to reveal

Current Workarounds

Care Coordinator uses paper scheduling + phone calls to caregivers day-of visit to remind them to clock in; maintains parallel calendar in Excel; manually reviews EVV logs post-visit to catch errors before billing • Compliance Officer manually audits EVV logs in spreadsheets; creates hand-written exception reports; communicates audit findings via email; uses paper-based compliance tracking • EVV Administrator corrects location coordinates; maintains manual notes on known GPS issues at specific addresses; reviews and corrects clock data manually

Unlock to reveal

Get Solutions for This Problem

Full report with actionable solutions

$99$39
  • Solutions for this specific pain
  • Solutions for all 15 industry pains
  • Where to find first clients
  • Pricing & launch costs
Get Solutions Report

Methodology & Sources

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

Evidence Sources:

Related Business Risks

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.

Fraudulent or Abusive Billing Uncovered Through EVV Audits and Investigations

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.

Request Deep Analysis

🇺🇸 Be first to access this market's intelligence