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EVV unlocked: The truth about the Choice Model & the billing aggregator myth [Webinar Recap]
It’s no secret that compliance regulations in the home-based care industry can be wordy—just take a look at the ever-important 21st Century Cures Act, which spans an entire 312 pages, to get a sense of how long-winded some mandates can be. As luck would have it, the extent of these pertinent laws often makes them downright confusing, leading to several misconceptions among providers.
The case in point for one of our recent webinars? The truth behind the Choice Model and the billing aggregator myth. Join two leaders in end-to-end solutions for Medicaid payers and providers, Michael Appel of AlayaCare and Kevin Wade of Sandata, to understand once and for all whether the 21st Century Cures Act requires the selected model to include the billing aggregator (spoiler alert, it doesn’t).
True: All states must collect EVV under the Cures Act
Electronic visit verification, more commonly known as EVV, is essentially a pre- and post-payment validation system to determine whether a state Medicaid agency or managed care organization (MCO) should pay a claim for Medicaid-funded personal care or home health services. Under the Cures Act, providers in all 50 states must collect and submit EVV for every Medicaid claim.
True: Most states have adopted a Choice Model
Since the Cures Act was signed into law in 2016, State Medicaid Agencies have had the flexibility to select from several system models to support EVV implementation. Though there are technically five EVV models to choose from, they can be categorized as a Closed Model or Choice Model:
Nine states operate in a Closed Model, including Connecticut and South Carolina. Though still a ‘Closed’ state, Texas provides a pool of State-approved EVV vendors for providers to pick from. Every other state falls under the Choice Model. For instance, New Jersey provides a vendor option but still allows providers to choose, whereas New York mandates providers select their own vendors.
False: The Choice Model includes billing requirements
States operating in a Choice Model implement a vendor-agnostic aggregator system to collect data from across EVV systems and ensure the proper standards are met. “There’s always going to be some process by which that data is taken out of your vendor system and gets transmitted to the proper place. But you’ll notice that data really is separate from your billing data,” explains Michael.
In other words, the Choice Model does not include a set billing aggregator.
However, vendors in some states have begun attempting to leverage their status as EVV aggregators into de facto mandatory billing vendors.
“We’re seeing some kind of captive pressure where these aggregators are saying, ‘Hey, to avoid billing issues, you might want to consider switching vendors because this is the aggregator we’re using.’ That almost effectively creates a pseudo-closed model, and it’s really taking the claims generation process out of the provider’s hands.”
Kevin Wade, Sandata
True: Pressure to switch vendors is creating challenges
When a third party enters the picture and interposes between the provider and the clearinghouse that receives Medicaid claims, State Agencies believe it may help combat Medicaid fraud and abuse. Ultimately, all it truly does is create a duplicative process. It forces providers to use multiple systems to generate claims, rendering issues with claims management, payment integrity, and processing.
The negative result
- Creates a process that interlocks EVV CURES Act submissions with billing and collections processes: Compromises to EVV data integrity, slower claims processing/payment, and significant expense to the providers.
- Compliance/audit: Changes are being made to provider submissions without consent so the aggregator can process the claims. This creates compliance risks and audit issues.
- Payment delays: Payments are becoming exponentially delayed with increased average collection times, in some cases over 250%, due to the administrative back-and-forth processing issues that arise when dealing with the “mandatory” aggregator.
- Captive pressure: Providers are forced to pay for unnecessary services to manage newly imposed requirements on claims processing of an MCO monetized clearinghouse because of the “mandatory” aggregator.
- Patient information: Critical patient information may be altered to expedite claims process and cash flow. This can lead to issues including claim rejection and reprocessing claims.
“Claims can get lost between you and the payer. You’re not really going to know what’s happening until you discover that you haven’t been paid. That’s just one weakness of this approach, but it’s an important one because there are definitely ways that payers can prevent fraud, waste, and abuse … without interposing nonstandard and extra steps into revenue cycle management.”
Michael Appel, AlayaCare
To conceptualize just how troublesome the pressure to switch vendors has become, watch the webinar below to hear from Julian Kang, the Assistant Director for Administrative Services at the Chinese-American Planning Council Home Attendant Program in New York. Together, Julian, Michael, and Kevin walk fellow providers through the truth behind billing in the Choice Model.
Watch the full webinar below!
Want to learn more about EVV? Take a look at our EVV FAQs page to learn more about how to comply with government EVV mandates and beyond.
