EVV Claim Recoupment in Georgia: What Home Health Agencies Need to Know

A recoupment notice rarely arrives as a surprise to the MCO — it's the end of a review process that started when an EVV exception went unresolved for months. Understanding how that process actually works, mechanically, is what separates agencies that can prevent recoupment from agencies that find out about it after the fact.

How Does EVV-Driven Recoupment Actually Work?

The mechanism is straightforward. An MCO conducts a post-payment review of paid claims and cross-references them against the corresponding Sandata EVV records. Where a claim has no matching EVV record, or the EVV record itself contains an unresolved exception (a location mismatch, a duration outlier, a missing required field), the MCO issues a recoupment or overpayment notice. The agency is then required to repay the identified amount, typically by withholding from future claim payments rather than a direct refund demand.

Which Exception Types Carry the Highest Recoupment Risk?

Not all exceptions carry equal weight in a post-payment review. Two categories drive the overwhelming majority of recoupment findings:

• Unmatched claims — a claim with no corresponding EVV record is the cleanest possible recoupment finding for an MCO reviewer. There's no EVV evidence the visit occurred as billed, which puts the full burden of proof on the agency.
• Location exceptions — a persistent, unresolved location mismatch raises the same question from a different angle: can the agency demonstrate the caregiver was actually at the patient's home for the billed visit?

Missing field, duration, and duplicate record exceptions carry real risk but are generally easier to resolve with documentation once flagged, which is why unmatched claims and location exceptions deserve priority attention in any internal review process.

What Are Typical MCO Audit Timelines and Lookback Periods?

Georgia's Medicaid MCOs — Amerigroup, Peach State Health Management, WellCare, and CareSource — generally conduct post-payment reviews on a rolling basis, with lookback periods that commonly extend 12 to 24 months from the review date, consistent with standard Medicaid program integrity practice. This means an exception pattern that goes unaddressed today can surface as a recoupment finding well over a year later, at which point the underlying documentation is harder to reconstruct and the dollar exposure has compounded across every affected claim in the lookback window.

What Appeal Rights Do Agencies Have?

Agencies that receive a recoupment or overpayment notice generally have a defined window — specified in the notice itself and in the applicable MCO provider manual — to submit a formal appeal or reconsideration request. A well-documented appeal typically includes corrected EVV records where the underlying visit did occur, caregiver attestations, and any internal exception log showing the resolution was in progress before the review. Agencies without contemporaneous documentation of their exception resolution process are at a significant disadvantage in the appeal process, since after-the-fact reconstruction carries far less evidentiary weight than a resolution log maintained in the normal course of business.

How Can Agencies Prevent Recoupment Before It Starts?

• Pre-claim exception review — catching and resolving EVV exceptions before the corresponding claim is submitted, rather than after an MCO review flags it, is the single most effective prevention strategy.
• Monthly monitoring — a recurring exception review process, rather than a one-time audit, keeps exception rates from drifting upward unnoticed between periodic checks.
• Documented resolution process — maintaining a written exception log with dates flagged, dates resolved, and resolution rationale creates the audit-defense record that makes an appeal viable if a recoupment notice does arrive.