Thirty-Five Million Dollars for Visits That Happened but Couldn’t Be Proven
A visiting nurse association faced this penalty not because visits did not happen, but because their EVV system could not prove they happened when auditors asked.
Documentation existed, timestamps were recorded, but the data was entered three days after visits. State auditors do not accept retroactive data entry as proof of service delivery.
Joseph Catan built MyVisits after spending 18 years as a Clinical Director defending agencies in exactly these audit scenarios. He recognized the pattern: agencies use scheduling systems to plan visits and separate EVV vendors to verify them.
When these systems do not communicate in real time, verification gaps appear. Those gaps surface during audits as compliance failures, threatening the 85% threshold MCOs began enforcing January 1, 2025.
In one recent case, an agency scheduled 1,847 visits in a month. Their EVV vendor captured 1,435 verification records. The remaining 412 visits had no audit-proof documentation. Those missing records represent the verification gap: the distance between what was scheduled and what can be proven to compliance standards.
The real question is not whether visits happened. The real question is whether your systems can prove visits happened at the moment of service when auditors demand evidence.
The Three-Layers Creating Compliance Gaps
Most healthcare agencies operate with three separate systems handling different aspects of service delivery. Understanding how they interact and where they fail explains why verification gaps exist.
Layer 1: Scheduling. Your agency management system assigns caregivers to clients and creates visit schedules. This layer manages who goes where and when. It tracks plans and intentions, not outcomes.
Layer 2: Verification. EVV platforms capture the six mandatory elements defined by the 21st Century Cures Act at the moment of service. This layer creates compliance documentation that verifies visits took place in accordance with audit standards.
Layer 3: Billing. Your billing system submits claims to payers based on verified visits. Billing depends entirely on the accuracy and completeness of verification data.
The gap appears between layers one and two. When scheduling and verification do not communicate in real time, agencies discover during billing, often weeks after services occurred, that scheduled visits lack compliant EVV records.
At that point, documentation becomes reconstruction rather than real-time capture. According to CMS guidance on EVV implementation, agencies must demonstrate that all six mandatory elements were captured at the moment of service, not reconstructed later or entered during batch processing.
How Disconnected Systems Create the Verification Gap
The workflow at many agencies reveals how disconnection becomes a compliance risk.
A Service Manager creates the weekly schedule in the agency management system and assigns visits to caregivers. Caregivers receive assignments and attempt to use a separate EVV mobile app. During the week, some visits are verified properly while others are not captured due to forgotten logins, application crashes, or connectivity problems.
At the end of the week, managers log into a separate EVV dashboard and discover missing verifications. Administrative staff begin contacting caregivers to reconstruct events. Some visits occurred without any EVV documentation. Staff manually enter data days later, creating timestamps that show when information was entered rather than when the service occurred.
Billing teams then identify incomplete documentation. Claims are submitted seven to ten days after services occurred. Staff may spend fourteen or more hours weekly reconciling fewer than fifty visits.
The root cause is foundational. Scheduling happens in one system. Verification happens in another. Data synchronization occurs in batches, if it occurs at all. Each integration point introduces delays, mapping errors, and documentation gaps that surface during billing.
What Real-Time Verification Looks Like
Agencies that use integrated verification platforms function more effectively because these systems eliminate synchronization gaps.
Service Managers continue creating schedules in their existing systems. Caregivers arrive at client locations and open the MyVisits mobile app. They scan a unique QR code at the client location.
At check-in, the platform captures all six mandatory EVV elements: type of service performed, individual receiving service, date of service, location of service delivery, individual providing service, and time service began. GPS verifies physical presence. Caregiver authentication confirms identity. The timestamp records the exact moment of service initiation.
At checkout, the caregiver scans again. The system captures the end time and calculates the service duration. GPS confirms location consistency. Automated mileage tracking records actual routes between visits.
The manager dashboard updates immediately. The visit status changes from scheduled to verified within seconds. Any missing data is flagged immediately while the caregiver is still available to address it. Completed visits flow to billing the same day with audit-proof documentation created at the moment of service.
The difference is fundamental. Real-time verification serves as the compliance layer between scheduling and billing, making sure every completed visit generates compliant documentation.
Five Diagnostic Questions That Reveal Verification Gaps
Does your system automatically update with EVV verification data when visits are completed? If not, you have a verification gap between operations and compliance.
Can you see real-time EVV status for today’s scheduled visits? If not, you discover missing documentation after the fact.
How long after visit completion is EVV data available for billing? Same-day availability indicates integration. Two to three days suggests batch processing. Weekly availability signals disconnected systems.
How many hours weekly are spent reconciling schedules, EVV logs, and billing records? Ten or more hours indicates manual cross-checking. Fewer than two hours suggests integrated workflows.
What is your current EVV compliance rate across all payers? If you cannot answer immediately, compliance is being measured reactively. If the rate is below 85%, corrective action plans and potential network termination are active risks.
Three or more negative answers indicate gaps that threaten compliance.
What State Auditors Actually Validate During EVV Reviews
State Medicaid auditors confirm that the six mandatory elements specified in Section 12006 of the 21st Century Cures Act are accurately documented at the time of service with tamper-proof verification.
These elements include: the type of service performed, the individual receiving the service, the date of service, the location of service delivery, the individual providing the service, and the start and end times of the service.
Auditors examine whether these elements were captured in real time. Paper logs completed later do not meet the standard. Systems allowing manual timestamp entry do not meet the standard. Batch processing that delays synchronization creates audit risk.
Common audit failures include mismatches between service types in scheduling and EVV records, location discrepancies due to mapping errors, and delayed timestamps caused by offline storage. These issues can lead to claim denials, financial clawbacks, extended review processes, and increased scrutiny.
The 85% Threshold and What It Costs When You Fall Below It
As recent as January 1, 2025, agencies that fail to maintain 85 percent EVV compliance for three consecutive months must implement corrective action plans. Continued noncompliance will risk network termination. This threshold is mandatory under federal requirements.
The revenue impact is direct. At an average reimbursement of $140 per visit, five missed or unverified visits weekly equals $36,400 annually. Ten missed visits weekly equals $72,800 annually. Twenty exceeds $145,000 annually, and those figures exclude visits that occurred but lacked compliant documentation and therefore could not be billed.
When agencies fall below the threshold, regulators trigger remediation plans. This leads to increased monitoring, potential reductions in authorizations, and weakened negotiating positions with payers, plus direct revenue losses.
Visit completion rates and documentation quality also influence star ratings, referral decisions, and eligibility for value-based payment arrangements. Verification gaps affect all of these.
Five Red Flags That Say Your Current System Creates Verification Gaps
- You discover compliance failures during billing cycles, not during service delivery.
- Service Managers spend ten or more hours a week reconciling systems.
- Mileage tracking requires manual logs or separate applications.
- EVV data takes multiple days to reach billing.
- You cannot determine your compliance rate without manual analysis.
Three or more of these indicate significant verification risk. The root cause in each case is the same: a system that separates scheduling, verification, and billing into disconnected workflows.
Platform Built by Operators, for Operators
MyVisits was built from 18 years of operational experience managing in-home services and defending agencies during audits. That background shapes how the platform works: every design decision reflects what Service Managers and Clinical Directors actually need when compliance is on the line.
Verification captured at the moment of service. QR code scanning at the client location confirms identity and captures all six mandatory EVV elements at check-in and check-out. GPS verifies physical presence. Timestamps document exact service windows. Automated mileage tracking calculates actual routes driven. Documentation is created at the time of service, which eliminates the risk of having to enter information retrospectively.
Integration with existing workflows. Agencies continue using their existing scheduling systems. Caregivers use the MyVisits mobile app for verification. Real-time data flows to dashboards and billing queues without manual reconciliation.
Same-day implementation. Cloud-based setup completes within one business day. No servers, hardware purchases, or IT projects required.
Transparent pricing. $39.95 per user per month. No setup fees, no annual contracts, no hidden charges.
The Enforcement Environment Has Shifted
Agencies now operate under active monitoring for the 85% compliance threshold. Scheduling software tracks plans. Bolt-on EVV vendors verify after the fact. Only a real-time verification system closes the gap between scheduled visits and compliant billing.
MyVisits offers a 30-day free trial with full functionality: QR code verification, GPS confirmation, automated mileage tracking, real-time compliance dashboards, and multi-state aggregator connections.
Schedule a 15-minute demo to evaluate verification gaps in your current workflow and assess your exposure under the 85% threshold. The system you operate today determines whether your agency maintains payer contracts or faces corrective action plans.
