Medicaid Fraud Oversight Now Runs on EVV Data: What Home Care Agencies Should Know

Medicaid fraud oversight in home care has moved from audits after the fact to routine data checks. A new KFF survey of state Medicaid officials, reported by Home Health Care News on Oct. 6, found all 48 responding states keep electronic visit verification (EVV) data in machine-readable files and cross-check billed claims against those records. Federal law only requires states to use EVV for in-home personal care and home health. States are going further on their own.

Two weeks later the federal side got louder. On Oct. 20, CMS deferred $1.2 billion in California Medicaid payments for personal home care services, on top of more than $1 billion deferred in July across California and Minnesota. CMS Administrator Dr. Mehmet Oz said the agency has "at least two more years of hard work to do on this." A deferral holds federal money until the state backs up the claims. Agencies don't get a personal warning, but the pressure reaches them through state reviews and tighter billing edits.

What Medicaid fraud oversight looks like at the claim level

Once a state matches claims to EVV, the questions get simple. Did the visit start and end where the plan says? Do the billed units match the recorded time? Is the caregiver who clocked in the same person on the claim? Twenty-one states told KFF they use, are piloting, or plan to use AI in their program integrity tools, including Michigan, Texas, Arizona and North Carolina. Those systems look for patterns, such as the same short visit billed every day or edits made long after a shift ended. An honest agency with messy records trips the same flags as a dishonest one.

KFF's authors also warned extra scrutiny brings new paperwork and pushes some providers out of Medicaid, which hurts access for clients. You don't control state policy. You do control how clean your own records look. Fix missed clock-ins the same day, with a short written reason. Compare scheduled visits against completed ones every week instead of waiting for billing day. And keep the people who correct visits separate from the people who submit claims, so every change gets a second set of eyes.

Visit records are the part of the work CareSync® was built around. We show planned versus completed visits side by side, so an office team spots a gap before it turns into a claim question. Whatever system you use, the goal is the same. When a reviewer asks about a visit, you want the answer in one place. We're also building something quieter on the side, a small invite-only circle where home health professionals compare notes on changes like these. More on that soon, hopefully.