Reaching desirable utilization of Electronic Visit Verification (EVV) inside the behavioral therapy space means getting the balance right in the face of widespread fraud, return on investment (ROI) challenges and increasing caps on mental health coverage.

“EVV is a critical component in comprehensive behavioral health management strategy,” said Vicky Duckworth, Senior Vice President of Government Operations at  eQHealth.

In her May 31 presentation at the 2018 EVV Summit, titled, The Role of EVV in Behavioral Health, Ducworth said she has “married” utilization management [UM] data and EVV data to evaluate intervention quality and to investigate correlations of actual supervision hours and goals met. Secondarily, work needs to be done to develop a system to deter fraud, activate guardian engagement, increase consumer protections and ensure that recipients obtain maximum benefit of coverages.

With health cuts looming on the horizon, however, a big question remains going forward: “How to train if mental health is getting cut?”

While uncertainty, high cost drivers and a lack of data are challenges facing the behavioral therapies space, opportunities abound.

A Growing Concern

Trends in the space need to be studied closely, like what is driving the utilization, said Ducworth, a former health care executive for Boeing.

For example, the CDC just released new numbers this year that showed a 15 percent increase in the prevalence rate of ASD [autism syndrome disorder], she said.

“We can’t really attribute that to the diagnosis; it may be we just have improved instrumentation, more fraud. The bottom line is that more diagnosis means more eligibility for behavioral therapies.”

Duckworth suggested going back five years, provider analysts will see a year-over-year increase in behavioral health diagnosis, noting that one in 67 children are now being diagnosed with autism.

Accurate data is just now emerging so no massive studies have been done, she said. Some data indicate between 16 to 27 thousand behavioral analysis providers in the last couple of years, many opening new clinics, independent practices. Many are young and inexperienced in business so “payers are eating it.”

The provider landscape is having a hard time, Duckworth said. The medical necessity criteria vary across the country. There is so little evidence. Government clients’ hands are tied. Nineteen states do not require licensure of these therapists, while these same states do require licensure of cosmetologists, she added, sardonically.

EVV Offers Solution

There are opportunities for EVV applications partnering with government partners as CMS required coverage of autism therapies a few years ago.

Most behavioral health plans have a cap, and when providers are fraudulently billing, then these children can’t receive the services they need after that maximum benefit has been hit. And there are implications relating to the long-term goals of those children. Also, the verification of service delivery is much more difficult because most interventions are delivered in the home setting, much like personal care services.

“There’s a constant parade of therapists in and out of the home,” she said, adding most children are prescribed up to 40 hours of therapy per week. “And there’s no third-party verification that these services were actually occurring.

Beyond the fraud issues, including improper payment, providers are doing a lot of self-reporting as a result of the lack of licensure requirements.

Behavioral therapy becomes critical for the care of ASD in children, she said, pointing to the lack of care for the Parkland, FL, shooter.

“There’s more than personal care as a use case for EVV,” said Tellus CEO Brad Levine, noting behavioral analysis and skilled nursing as just two of several. “[EVV] will grow into a much broader solution set with more specific nuances around different programs.”

“We have an opportunity clearly flying under the radar, and that’s the behavioral health space,” Ducworth said.