A.5750/S.6123 – Electronic Visit Verification Requirements

This legislation, A.5750/S.6123, would require home care providers to use forms approved by the federal Centers for Medicare and Medicaid Services (CMS) to submit claims, and would allow providers to submit claims directly to Medicaid managed care plans.  The language in reference to the CMS “form” is confusing, since claims are submitted and processed in compliance with HIPAA standards under federal law.  Further, we believe language that states “claims shall be submitted to insurers directly” would violate federal electronic visit verification (EVV) requirements. In relation to EVV, the NYS Office of Medicaid Inspector General (OMIG) website states:

“The [verification organization] VO must verify the home health service(s) within the claim or encounter, collected from the electronic visit verification (EVV), prior to submission of the claim or encounter to the Department of Health (DOH) or to a managed care provider.”

Today there is no centralized “clearinghouse” for EVV transactions where all providers submit and all plans can access to verify visits.  A centralized clearinghouse would be an essential pre-requisite in an environment where providers to submit claims directly to plans, to provide plans with a source of truth when verifying visits prior to claims payment.  When implementing EVV requirements, New York State made a decision not to require a specific VO, which has resulted in some inconsistency in implementation.   We have concerns that this language could have unintended consequences in regard to the State’s ability to comply with federal EVV requirements.

For these reasons, HPA has concerns regarding A.5750/S.6123.