Basics of Medicaid Compliance: 5 Things to Keep in Mind

Basics of Medicaid Compliance: 5 Things to Keep in Mind

Basics of Medicaid Compliance: 5 Things to Keep in Mind

When home care agencies decide to expand their payor sources and provide services for Medicaid recipients in their state, there are several factors to remember. While expanding payor sources can substantially increase revenue, the challenge lies in compliance.

Medicaid is completely different from private pay and even Veterans Administration billing. Adding Medicaid as a payor source should be done after thoughtful consideration and proper research to ensure compliance with state and federal regulations.

When adding Medicaid recipients to your client roster, here are several things to consider:

Medicaid License Rules Vary State by State

Has your home care agency been authorized to provide Medicaid services in the state it services? All states that have Medicaid require home care agencies to be certified and licensed to be reimbursed by the state.

There’s likely a lengthy application process that leads to being registered as Medicaid-certified in each state. Agencies should never assume that because they’ve been authorized to provide Medicaid services in one state, they can be provided in a different or neighboring state. That is not the case, as each state requires its own registration and has its own processes.

In some states, agencies must register in every county they wish to serve. Research to see what your state requirements are so your agency gets approved and stays compliant.

Aggregators Are a Key Piece of the Medicaid Compliance Puzzle

Learn who the EVV aggregator(s) is/are for the state your agency serves or if you even have an aggregator. Not all states do.

When agencies register on their state’s website, it will specify which company (aggregator) collects electronic visit verification (EVV). The site will also explain if the state’s software system is required for EVV or if the agency can choose any EVV vendor they wish to work with.

What is an EVV aggregator? Essentially, it’s a data warehouse. The state aggregator collects all the EVV data it receives from home care agencies providing Medicaid services. The aggregator then puts all that data in a digital warehouse so the state can go in after each billing cycle has been completed and compare agency billing to the data the aggregator has stored.

This allows the state to ensure visits are billed for match visits provided, agencies are compliant, and there is no fraud taking place. Agencies must ensure all billed units match the EVV data collected by the aggregator or EVV vendor.

To make sure this is working correctly, agencies have to do the following accurately:

  • Bill the right service and corresponding procedure code
  • Bill the right number of units so that billing hours match
    • If caregivers are clocking in and out for hours they cannot bill for, the agency will not be reimbursed for that time.

Provider IDs Differ Depending on the State

What are your specific provider IDs for your specific state? Some states only supply one ID per agency, which identifies that agency to the state. Other states like Missouri (based on the type of care provided) and Georgia (based on the programs provided) provide multiple state IDs for each agency.

This is important because to be compliant, all data has to be:

  • Input correctly
  • Organized in the right place
  • Delivered to the state in the correct way and under the correct provider ID

Focus on Day-to-Day Compliance

Since passing the 21st Century Cures Act, EVV has become mandatory for most services.

Once a home care agency has determined who their state aggregator is, it’s a good idea to look at the list of Medicaid services (i.e., homemaker, chores, respite, etc.) that have to be aggregated.

States will have a spreadsheet that shows:

  • Each Medicaid program name
  • Procedure codes in that program
  • Whether EVV is required for those procedure codes
  • Any additional information that’s required, such as tasks

Agencies need to know per-service if clock-in and clock-out information is sufficient or if task information or client signatures are required. For example, some states, like Missouri, require task information for some, but not all, procedure codes.


Let’s be honest. The biggest challenge agencies will face with EVV is getting caregivers to clock in and out on time consistently.

When we say “on time,” it’s important to recognize that schedules change weekly. That being said, EVV should reflect the right amount of units, and caregivers should only be assigned the number of hours they are authorized to work.

This is why agencies should create a caregiver schedule – for transparency and consistency. Creating schedules helps caregivers get into the habit of clocking in and out consistently. Schedules also help caregivers know when they’ve reached their hours limit so they don’t provide services the agency will not be reimbursed for.

Every agency’s goal should be to have 100% of shifts with clock-ins and outs. Agencies should treat every shift where that goal is not achieved as very serious. These are the “receipts” the state will be looking for to provide reimbursements.

In all honesty, that’s a very lofty goal, but it should remain the goal nonetheless. That said, life happens, and caregivers will forget, get stuck in traffic, or have a car that won’t start. It’s happened to all of us.

Backup Documentation

A 100% clock-in/out goal is what agencies should work hard to achieve, understanding that when that goal isn’t met, they need to have backup documentation about why things didn’t happen correctly.

If the state comes later and conducts an audit, they’re going to ask, “Why did this happen?” and “What did you do to confirm that visit?” If agencies cannot confirm a visit, they cannot bill for it.

What sort of backup documentation should an agency collect without electronic visit verification?

  • Call the caregiver and ask what happened
    • Did they forget?
    • Was the internet out?
    • Did they have trouble with their phone?
    • Did they have trouble with the client’s phone?
  • Confirm with the client when the caregiver arrived, provided the correct services, and left
  • Have written documentation that states the agency did both of those things

Those requirements are the bare minimum. A paper timesheet signed by the client, scanned, and stored in the agency’s home care software system is the least amount of documentation that should be collected. The next step is to tell the state when doing billing why the EVV event didn’t happen.

Reason Codes

To tell the software why an EVV event is missing, agencies have to use a reason code or an “exception code.” The state provides a set list to choose from, so they need to be as close to the caregiver’s actual reason as possible. Be pretty strict with how often the general “other” reason code is used.

Each state has a maximum number of manual EVV events or manual edits to EVV it allows. For example, Delaware only allows 10% of all EVV events to be input or edited manually. Therefore, agencies have to be very diligent and on top of things.

It’s better to have any EVV than no EVV. If a caregiver gets distracted and forgets to clock out until they get home, agencies should still have that caregiver clock out. Then, agency staff should note that incident, including verifying when the caregiver completed the shift with the appropriate documentation mentioned above.

Software Solutions

Home care management software is designed to do the heavy lifting. Agencies should know the features available through their scheduling software to make the EVV process easier.

For example, if caregivers complain about spotty Wi-Fi, the agency should see if their software includes Offline Mode and train their caregivers on how to use it. This feature collects the GPS and EVV data while internet or mobile data are unavailable, then uploads it once connectivity is restored.

Free Isn’t Always Free

Free EVV software services the state provides are not always the best tool for managing home care agencies. The main focus of each state aggregator is typically to store EVV data. Other services they provide beyond that are often secondary to that goal.

Third-party EVV software vendors provide operations software specifically for day-to-day operations. They know the challenges agencies are likely to face daily and provide custom tools to manage so much more than clock-ins and outs.

Just because aggregators provide “free” clock-in and clock-out functionality does not mean they provide free scheduling, billing, and payroll. Those features are add-ons that must be paid for by the agency. In many cases, those add-ons are not customizable. It’s not worth their time for those large aggregators to adjust their software, services, and customer care for your specific client needs if you’re a smaller agency.


Agencies should often compare their third-party software system with the state’s aggregator software. Ensure the information your agency sends over through software integration arrives in the aggregator. A lot can happen in between two software systems, even if they’re integrated.

It’s on the agency to ensure the visits they provide are in the aggregator. If they’re not, the first step is to check with your software vendor and ask what’s happening. It’s also possible that the state hasn’t yet uploaded the client data into the aggregator, and your agency will need to reach out to the state to speed that process up.

Clients must be in the aggregator before agencies can send clock-ins/out for that client. States get backed up, so it’s possible a new client might have been missed or delayed. Procedure codes could be labeled incorrectly. Reason codes might have changed.

Recently, the Centers for Disease Control updated diagnosis codes for patients with Parkinson’s disease. This affected all Medicaid aggregators, including HHAeXchange, Sandata, and Netsmart (formerly Tellus). These codes must be updated in each client with that code before billing can happen.

It’s important not to panic when issues arise. Instead, reach out first to your software vendor’s customer care team and move up the chain as necessary.

In the end, adding a new payor source, such as Medicaid, can add significant revenue to an agency seeking additional clients. It’s important before moving forward to do the necessary research to ensure your agency fully understands the intricacies of the Medicaid program, as rules differ by state.

For more information about adding Medicaid clients to your roster, reach out to your software vendor for guidance, or feel free to contact Rosemark to see how we can help your agency get set up to bill Medicaid.

Rosemark - Your Partner in PeopleCareAbout Robin Tuck
Senior Product Owner and Project Manager

Guest blog for corecubed

Robin Tuck is the Senior Product Owner and Projct Manager at Rosemark, a home care management software provider. A seasoned veteran in the home care technology space, Robin is passionate about finding creative solutions to help her customers get the most out of their software, so they can focus more on their caregivers and clients. When she’s not working, she’s probably writing, taking walks, or watching the family of raccoons that have set up camp in her backyard.