Objective

To determine whether Medicaid made payments for personal care and home health care services that were not supported by required electronic visit verification records. We examined paid personal care services with service dates from January 2021 through March 2023 and paid home health care services with service dates from January 2023 through March 2023.

About the Program

The Department of Health (DOH) administers the Medicaid program. In accordance with the federal 21st Century Cures Act (Cures Act), New York State implemented an electronic visit verification (EVV) program for all Medicaid personal care (PC) services in January 2021 and home health care (HHC) services in January 2023. EVV systems must capture the provider, recipient, service type, date, location, and begin and end times. For example, caregivers can use an application on their mobile phone to submit this information while in the home providing services. To implement the EVV program, DOH selected the “Choice Model,” which allows PC and HHC providers to select and fund their own EVV system for submitting EVV records to DOH. A major goal of the EVV program is to validate service delivery by allowing entities to match EVV information to Medicaid claims to identify improper services charged to the Medicaid program.

In addition, New York State Social Services Law required PC and HHC providers with Medicaid reimbursements that exceeded $15 million a year to use a verification organization (VO) to conduct pre-claim reviews (using EVV records as well as other information) to verify PC and HHC services on claims prior to submission of the claims to Medicaid. The Office of the Medicaid Inspector General (OMIG) was required to develop a list of providers that met the VO requirement and notify them of the requirements.

Medicaid paid over $31.5 billion for PC services from January 2021 through March 2023, and about $109.8 million for HHC services from January 2023 through March 2023.

Key Findings

• Medicaid paid claims totaling $14.5 billion for 82 million PC services and $97.6 million for over 400,000 HHC services that did not have matching EVV records. This equated to matches of only 56% of PC services and 11% of HHC services. The audit identified a range of oversight and internal control deficiencies that contributed to the high volume of unmatched services.
• Medicaid paid claims totaling $11.6 million for 54,833 PC services that did not indicate valid services because they were too short in duration (under 8 minutes) to be billable under Medicaid rules. In addition, PC and HHC services should be suspended while a recipient is hospitalized; however, we found 65,626 PC and HHC services, totaling $9.7 million, occurred while recipients were hospitalized.
• OMIG did not take steps to help ensure providers that were required to use a VO for pre-claim reviews actually obtained a VO for that purpose. OMIG only notified 32 providers in 2015 of the requirement. We identified an additional 153 providers that, based on PC payments made to them during calendar year 2021, met the VO requirement. For example, of six providers we sampled that met the $15 million threshold, five were not notified by OMIG and did not obtain a VO for pre-claim reviews. The VO requirement ended in January 2024. Despite the numerous control deficiencies we identified in the audit, DOH planned on relying on the EVV program to offset the lack of required VO pre-claim review.

Key Recommendations

• Review the $14.5 billion in PC services and $97.6 million in HHC services with no matching EVV records and take steps to ensure these services are properly supported with EVV data.
• Improve oversight of the EVV program and establish key controls to ensure EVV compliance, including developing controls that prevent payment of claims for PC and HHC services that lack supporting EVV records.
• Review the $11.6 million for PC services under 8 minutes and the $9.7 million for PC and HHC services provided during hospital stays and recover overpayments, as appropriate.