In December 13, 2016, the 21st Century CURES Act required all states to implement Electronic Visit Verification (EVV) for Medicaid-funded services. This mandate has been extended multiple years for implementation, and required a personal care services mandate by January 1, 2021, and for Medicaid-funded home health care services to be mandated by January 1, 2023. As many are aware, Centers for Medicare & Medicaid Services (CMS) has again released the ability for states to apply for a Good Faith Exemption to allow states an additional 365 days to be compliant for home health services, to be live by January 1, 2024.
As the upcoming compliance timeline is quickly approaching, we thought it would be interesting to discover how the initial phase and implementation of EVV has affected managed care organizations (MCOs), and their provider networks. Netsmart recently hosted a webinar that addressed the details of this topic with the talented Dr. Melissa Berdell, Director Fraud, Waste and Abuse at Highmark Wholecare, a Netsmart client.
Highmark Wholecare, formerly known as Gateway Health, is an MCO headquartered in Pittsburgh, PA. The organization manages care for Medicaid and Medicare programs and works with more than 29,000 primary care physicians, specialists and other providers. Their goal is helping members achieve not just physical health but also delivering whole-person care through community outreach and engagement programs.
Speeding resolution of member complaints
Prior to EVV, Dr. Berdell noted that investigations into members’ complaints about services not received required a lengthy process.
“We had a multi-phase protocol that involved data mining, going through medical records and referrals to validate information. We looked at timecards, interviewed members and caregivers to determine what was going on,” she said. “It was a time-intensive process that often took months or even a year or more.”
With EVV, the process has become much simpler because the platform can validate via telephony and GPS records whether the caregiver is doing the work, near real-time.
“Real-time data from the EVV platform effectively takes waste, fraud and abuse out of the equation, Dr. Berdell explained. “When we get the case, it is a matter of logging onto the EVV platform. We can see instantly if the referral is credible and can close cases quickly – sometimes within a day.”
Moving from post-payment to pre-payment review
As a result, Dr. Berdell has seen the focus of her department change to a more proactive mode.
“The gold standard in waste, fraud and abuse is pre-payment review, instead of post-payment, where you pay the claim and hope everything has been provided,” she explained. “EVV makes it possible to see red flags much sooner. If there is a discrepancy in the data, we can deny the claim, reach out to providers to see what’s causing it and fix it.”
Quick resolution of simpler, more straightforward issues such as overpayment for an individual’s care also gives Dr. Berdell’s department more time to investigate more complex instances of criminal fraud.
Reaping the benefits of EVV 2.0
Highmark has moved beyond the initial goal of complying with EVV to a second phase in which data collected is used to create insights into the needs of the individual, improving outcomes. Dr. Berdell said she feels this aspect of EVV will be even more important when it becomes mandatory for home health care in 2023.
“We have data from providers who are ‘in the home,’ sometimes . Case managers will be able to see if the plan of care is being followed. If it is, and members aren’t making the progress expected, adjustments can be made to better address their needs,” she said.
This allows a more holistic approach to providing whole-person care extending member benefits to take advantage of other programs that we may offer with that information.
Raising quality by monitoring SDoH
EVV is also giving Highmark the ability to address needs related to social determinants of health (SDoH) that may have been missed previously.
“Highmark is looking at our members’ support systems both in the home and in the community,” Dr. Berdell explained. “Collecting data frequently and in real time means we’ll know exactly when food insecurity becomes an issue, for example. It may not be a problem when a member sees a doctor earlier in the month, but later in the month it is. Having this information means we can get our SDoH team involved to address those gaps and improve outcomes.”
For Highmark and Dr. Berdell, EVV has evolved beyond ensuring claims are paid appropriately. It is now a way to elevate the level of care.
“The less medical expense we have related to fraud, waste and abuse, the more resources we devote to members’ needs and care. With the data collected, we also can gauge both the quality and effectiveness of that care. Because our goal is to ensure our members’ wellbeing – physically, mentally and financially.”
To learn more about how Highmark is using EVV to elevate care, watch the full webinar here.
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