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Private pay is the most widely accepted form of payment in home care, but it is not the easiest to navigate. Many providers struggle with its unpredictable nature and experience fluctuations in their revenue because of this.
The success story of HouseWorks, a Greater Boston-based provider, serves as a compelling testament to the power of diversifying your payer lines. They managed to grow their annual revenue from $25 million to $400 million in a few years through expansion into Medicaid.
So what's stopping you from doing the same?
If it's a lack of familiarity with the Medicaid program, then we've got your back! Read our brief Medicaid provider manual below to learn everything you need to know.
The Benefits of Expansion into Medicaid
Why are home care providers embracing Medicaid? Here are a few of the reasons why Medicaid is such a lucrative opportunity for providers:
1. Bigger Client Base
Medicaid is the largest public health program covering over 72 million US citizens so there is a higher volume of work especially in states with large Medicaid programs.
2. Reduced Risk
Having multiple sources of service offerings mitigates risk and allows you to expand your business to include federal, state, and private payers.
3. Improved Cash Flow
Medicaid reimbursement rates, though varying by state, can provide a reliable income stream, contributing to the financial sustainability and growth of your business.
4. Caregiver Retention
There is potential for a high volume of authorized hours which can attract and retain caregivers.
This is the reason why many home care agencies are getting involved in Medicaid. If you’re looking to get started, here is everything you need to know about the program.
What Is Medicaid?
Medicaid is a joint state and federal health insurance program for lower-income individuals, people with disabilities, children, and other select few. It's the biggest program in the US covering over 1 in 5 Americans.
The federal government has a set of rules that all state Medicaid programs need to abide by, but each state runs its own Medicaid program. Thus, eligibility requirements and benefits could differ by state.
What Is the Medicaid Waiver Program?
Medicaid waivers serve as an instrumental tool that states can utilize to expand coverage and alter how Medicaid is run and paid for.
The Medicaid waiver program empowers states to select specific groups of individuals with distinct needs and health conditions, offering customized healthcare solutions either in their homes or within the community.
Abiding by federal guidelines, individual states can initiate Home and Community-Based Service (HCBS) waivers if they can prove that the waiver service:
- Does not exceed the cost of the same service in a healthcare facility.
- Safeguards an individual's health and well-being.
- Offers standards that are both reasonable and sufficient to fulfill an individual's requirements.
- Tailors a care plan specific to the individual.
Medicaid waivers are available in all states and you can view existing ones on the state waivers list.
Electronic Visit Verification Explained
What makes Medicaid unique is its Electronic Visit Verification (EVV) system. This ensures that care is delivered as authorized and reduces the risk of fraudulent activity as it electronically timestamps and geo-tags service details. This includes confirming the service type, recipient identity, date, location, service provider, and the start and end times of the service.
Now this is where it gets a bit complicated...
States either follow an open or closed model when it comes to EVV. In the closed model, there's a single EVV vendor, ensuring consistency but adding pressure on the state, providers, and caregivers.
The open model lays down fundamental EVV guidelines, allowing providers to choose their own systems after which a universal EVV aggregator is used to pull all the information together.
How Does Credentialing Work?
Providers are required to submit an application to their relevant state Medicaid agency. Each state is unique so the application process may differ depending on where your agency is based.
Your application will be reviewed and your credentials will be verified. Once approved, you will be enrolled as a Medicaid provider and can now serve Medicaid beneficiaries and receive reimbursements.
NB: Check your contract dates so that you know when you need to get recredentialed.
Medicaid Billing and Reimbursement
There are strict Medicaid billing guidelines that providers need to follow. You will receive an authorization detailing the number of hours a client can receive and if you exceed these hours it's important to know that you won't be reimbursed for the excess.
The CMS-1500 form, also referred to as the Professional Paper Claim Form, is used to bill for medical services provided to clients under Medicaid.
Billing becomes quite tricky because of the EVV systems in place. You need to ensure that your claims match your EVV data, which has to match the EVV data that the state has.
If you'd like a more in-depth explanation of the EVV system and how credentialing and Medicaid billing and reimbursement work, then check out this article: Navigating Home Care Medicaid: A Practical Guide
Script Your Success Story with Paradigm
Growing with Medicaid is not easy, and providers often find the tasks of coding, submitting claims, tracking, and following up to be excessively time-consuming.
But Paradigm helps alleviate this burden so that you can simply focus on growing your business. Let us help you script your very own success story by becoming a part of the 2000+ home care agencies that trust Paradigm with their third-party billing needs.
