Medicaid accounts for 57% of Long-Term Supportive Services for adults at home in the US, making it the largest public health program serving over 72 million citizens.
Despite this, Medicaid is an underserved payer line as navigating its various programs and Electronic Visit Verification (EVV) systems can be challenging for many home care agencies. This guide is designed to help home care agencies enhance their understanding and ability to navigate the Medicaid system more efficiently.
An Overview of the Various Entities Involved in Medicaid
Medicaid funding comes from both the federal government and individual state governments. The federal government sets standards and guidelines, while states have the flexibility to tailor the services they provide.
There is often confusion surrounding Medicaid’s home care benefits due to the presence of multiple Medicaid programs in each state, each having unique offerings and regulations.
States offer a variety of Medicaid programs, including the State Plan, Institutional Medicaid, and Medicaid Waivers such as Home and Community Based Services.
In certain states, enrolment with Managed Care Organizations (MCOs) is necessary to provide care to Medicaid clients. Providers may need to enroll or get credentialed with each MCO to accept clients covered by that particular payer.
Medicaid State Plans typically cover home care through Personal Attendant Services (PAS) or Personal Care Services (PCS) in the majority of states.
What Are Medicaid Waivers?
Waiver programs allow states to implement new strategies under the Medicaid framework that deviate from federal requirements. These programs can expand coverage, modify service delivery, and change how Medicaid is funded and managed.
Medicaid waivers are approved by the Centers for Medicare & Medicaid Services (CMS) if they align with the objectives of the Medicaid program. These waivers frequently include coverage for home care as a nursing home alternative.
How Does Medicaid Work?
Medicaid includes a comprehensive credentialing process, Electronic Visit Verification (EVV), and precise billing requirements.
Medicaid Credentialing
Providers interested in participating in Medicaid must submit an application to the appropriate state Medicaid agency.
The Medicaid agency conducts a thorough review of provider applications to verify their credentials, including medical licenses, certifications, education, training, and experience, to ensure they are qualified to offer services under the Medicaid program.
Providers are subject to background checks to verify they have no history of fraud, abuse, or other disqualifying factors. In some states, on-site visits are required during the credentialing process.
After verifying and approving the provider’s credentials, they are enrolled as a Medicaid provider, allowing them to offer services to Medicaid beneficiaries and receive reimbursements.
It is important to be aware that Medicaid credentialing requirements and processes can differ between states, so it is recommended to reach out to your state’s Medicaid agency or relevant Managed Care Organization (MCO) for accurate information.
Electronic Visit Verification (EVV)
Electronic Visit Verification (EVV) is a component of the Medicaid program that helps monitor and track services provided by home healthcare providers to ensure compliance and accuracy and reduce fraud.
EVV systems utilize electronic time-stamping and geo-tagging technology to confirm details such as the service provided, recipient, date, location, caregiver, and duration of service.
Home care agencies need to have EVV in place to be able to work with Medicaid, which can be either a chosen EVV system or one mandated by the state. This is referred to as the open versus closed model.
The closed model requires providers to use a specific EVV vendor, while the open model allows providers to choose their own system and utilizes a universal EVV aggregator to integrate all data.
EVV aggregators collect and standardize live data to compare against submitted claims.
It’s worth noting that even within a single state, there are various programs with different EVV requirements, leading home care agencies to potentially utilize multiple systems.
Medicaid Billing and Reimbursement
The Medicaid reimbursement and billing process has specific guidelines that providers must adhere to. Home care agencies will receive authorizations detailing the hours their clients can receive. It is important to only provide services within the authorized period, as Medicaid will not reimburse for hours outside of this timeframe.
Claims must also align with EVV data, which should match the information on file with the state from the EVV aggregator.
A common challenge with Medicaid billing is high denial or rejection rates. These rates are often attributed to scheduling errors and inaccurate documentation regarding client visits. Providers also struggle with payment reconciliation on the backend.
Achieving success in Medicaid requires adherence to state regulations, proper use of Electronic Visitation Verification (EVV), and meticulous documentation to ensure accurate reimbursement.
Empowering Home Care Providers
To master Medicaid, agencies must navigate the nuances of state regulations, EVV systems, and billing procedures. This guide serves as a valuable resource to enhance agencies’ understanding and proficiency in maneuvering through the complexities of the Medicaid system. As the largest public health program, Medicaid demands careful attention to detail and a commitment to compliance for the successful provision of home care services.
If you have questions about EVV software, please reach out to the Rosemark team for more information.