Medicaid is one of the most widely embraced payer lines in home care. However, many agencies struggle with the nuances of all the different programs, Electronic Visit Verification (EVV) systems, and more.
In this guide, we aim to provide home care agencies with the knowledge and understanding they need to navigate the Medicaid system more effectively.
Before we begin, the most important thing to remember with Medicaid for home care is that every state has its own policies and programs, and each program may have multiple avenues. Just because something is true in one state, or for one program, does not mean it carries over to another.
The Medicaid Opportunity
Medicaid alone makes up 57% of all Long-Term Supportive Services (LTSS) being provided across the country for adults at home. It’s the largest public health program serving over 72 million US citizens and it’s still growing.
Medicaid is a great opportunity to diversify your payer lines and simultaneously mitigate risks by expanding your business to include state, federal, and private payers which will in turn enhance cash flow.
It is an underserved payer line in home care, and it can also help with caregiver retention due to the high volume of authorized hours.
The Different Players in Medicaid
Medicaid funds stem from both federal and individual state governments, leading to a dual source of rules that oversee the program. While the federal government establishes specific standards and guidelines, states have flexibility in shaping the services they offer.
Confusion with Medicaid's home care benefits arises from the existence of multiple Medicaid programs within each state, each with its own distinct offerings and regulations.
States house a Medicaid State Plan, occasionally known as Regular Medicaid or State Medicaid, alongside Institutional Medicaid, which excludes home care coverage. Therefore, as an alternative to Institutional Medicaid, there are Medicaid Waivers, often referred to as Home and Community Based Services, HCBS Waivers.
Some states work alongside third-party organizations, Managed Care Organizations (MCOs), to manage and deliver care to Medicaid clients. They are considered the payer in this case, and you may have to get enrolled/credentialed with each MCO to be able to accept clients covered by that specific payer.
Medicaid State Plans pay for home care under Personal Attendant Services (PAS) or Personal Care Services (PCS), in most states.
Medicaid Waivers
Waiver programs provide states with the opportunity to explore innovative approaches within the Medicaid framework that differ from federally mandated provisions. They are used to broaden coverage, adjust delivery methods, and reshape how Medicaid is financed and run.
If the Centers for Medicare & Medicaid Services (CMS) believes it is beneficial to the objectives of the Medicaid program these waivers are likely to get approved. Medicaid Waivers often cover home care and serve as an alternative to nursing homes.
How It Works
Medicaid has some unique factors including a thorough credentialing process, Electronic Visit Verification (EVV), and strict billing requirements.
Credentialing
Providers looking to get started with Medicaid must submit an application to the relevant state Medicaid agency. Each state has its own Medicaid program, so the application process differs by state.
The Medicaid agency will review the application and verify the provider's credentials, which may include their medical licenses, certifications, education, training, and experience. This ensures that the provider is qualified to offer the services they intend to provide under the Medicaid program.
Providers may undergo background checks to ensure they have no history of fraud, abuse, or other disqualifying factors. Some states require on-site visits as part of the credentialing process.
Once the provider's credentials are verified and approved, they are enrolled as a Medicaid provider and can now offer services to Medicaid beneficiaries and receive reimbursements.
Home care agencies may have to repeat this process for every program and payer that they want to do business with.
Medicaid providers need to get recredentialed periodically and need to ensure that they don't miss the allocated dates as this could lead to suspension.
Medicaid credentialing requirements and processes can vary from state to state so make sure you communicate with your state's Medicaid agency or relevant MCO.
Electronic Visit Verification (EVV)
Electronic Visit Verification (EVV) is a unique aspect of the Medicaid program. EVV systems help ensure that services provided by home health care providers are delivered as authorized and that all visits are accurately tracked.
EVV requirements were intended to reduce fraud and save money. The effects of EVV will depend on how it is used in each state. EVV systems use electronic time-stamping and geo-tagging technology to verify the type of service performed, the person receiving the service, the date, location, person providing the services and the time the service begins and ends.
Methods of EVV include, for example, tracking a provider’s location at the start and end of each visit and sending that data to the state Medicaid agency. Other methods require a provider to be in a pre-determined location at the start and end of each visit.
States decide how to implement EVV and are at different stages in the process.
Home care agencies must be set up with EVV to work with Medicaid, this may be an EVV of choice, or an EVV mandated by the state. This is known as the open vs. closed model.
The closed model only allows for one specific EVV vendor, making things consistent but also putting some strain on the state, providers, and caregivers. On the other hand, the open model lays down basic EVV rules and lets providers pick their own systems, and then uses a universal EVV aggregator to pull it all together.
EVV Aggregators gather, process, and organize this live data into standardized formats. This standardized data is then used for cross-comparison against the claims you have submitted.
It’s important to remember that even within a single state, there are different programs, and payers/MCOs may have their own EVV requirements, which could lead to some home care agencies having to use multiple systems.
For example, Max is an agency owner in Connecticut (closed model) and Indiana (open model). He provides Personal Care Services through Medicaid for clients in both states and uses Wellsky as his AMS.
Indiana is an open model state, meaning, Max can have his caregiver's clock in and out through Wellsky, and as long as Wellsky is integrated with the state's EVV aggregator, the shifts will automatically be loaded into the EVV Aggregator system (Sandata, HHAeXchange, etc.)
Connecticut is a closed model state, meaning, caregivers must clock in through Santrax software (a version of Sandata and EVV aggregator), if Max wants to track shifts through Wellsky, caregivers will have to clock in through Wellsky and Santrax seperately, because the state doesn’t allow Wellsky to integrate with their EVV aggregator (Santrax). The only way the shifts will be verified is if the caregiver clocks in through Santrax.
Billing And Reimbursement
The Medicaid reimbursement and billing process has strict guidelines that providers need to follow. Home care agencies will receive authorizations that outline the number of hours their client can receive.
You need to ensure that you don’t set up hours outside of the authorization period as Medicaid won’t reimburse you for those hours. You also need to ensure that your claims match your EVV data, which has to match the EVV data that the state has on file from the EVV aggregator.
One of the main challenges with Medicaid billing is that the denial or rejection rates are quite high at 20-30%. The two most common reasons are scheduling errors and incorrect documentation on client visits. Another issue many providers have is payment reconciliation on the backend.
Paradigm’s home care Medicaid billing is an excellent option to avoid billing denials or rejections. Our solution guarantees stability and effectiveness by maintaining precise EVV data, automating billing processes, adhering to rates and policies, conducting client eligibility checks, and streamlining authorization procedures.
We handle all of these issues with ease, so you have one less thing to worry about.
Mastering Medicaid
After gaining some insight into the world of Medicaid, one thing is certain - precision is key. It is important to comply with state regulations and guidelines, utilize Electronic Visitation Verification (EVV), and maintain accurate documentation for successful reimbursement.
With Paradigm, embrace billing success – from accurate EVV to streamlined processes, we've got you covered.
.webp)
