A Medicaid home care claim can only be paid if the visit behind it verified. Here are the seven places verification breaks — and why some of the money is recoverable and some is already gone.
Since the 21st Century Cures Act, every state Medicaid program requires electronic visit verification for personal care services, and most now require it for home health. Each visit must capture six data points: the type of service, the person receiving it, the person providing it, the date, the location, and the time the service begins and ends.
Those six data points are checked — by the agency's EVV vendor, the state's aggregator, or the payer's claim system — against what was scheduled and what was authorized. A claim is paid only when everything matches. Most of the revenue an agency loses to EVV is lost in that matching, not in the care itself: the hours were worked and the wages were paid, but somewhere between clock-in and remittance a check failed.
An exception happens before billing: the visit record fails a check inside the EVV system or aggregator — a missing clock-out, an unmatched caregiver ID — and the visit never becomes a clean claim. Until someone fixes it, there is nothing to deny, because nothing was submitted. Exceptions are invisible on remittance reports, which is why owners who watch denials closely can still be losing more to visits that were never billed at all.
A denial happens after billing: the claim went out and the payer refused it — wrong authorization, duplicate, eligibility lapse. Denials at least appear on a report. Both are recoverable while the state's timely-filing window is open; both become permanent losses the day it closes.
1. Missed or failed clock-ins. The most common exception. A caregiver forgets to clock in, a phone dies, an app loses signal, or a telephony call comes from a number the system doesn't recognize. The visit happened; the record says it didn't. Most systems allow manual verification after the fact, but each one takes office time and documentation.
2. Location mismatches. GPS-based systems check the clock-in against the member's address. A caregiver who clocks in from the parking lot, a rural address with poor GPS accuracy, or a member who receives care in the community can all put a visit outside the acceptable radius and flag it.
3. Caregiver linkage problems. The person providing care must be identifiable and, in most states, linked to the member in the system — correct ID, active status, sometimes registry enrollment or current credentials. A caregiver hired last week who isn't fully set up yet generates exceptions on every visit they work.
4. Authorization problems. The claim must fit inside an active authorization: right service code, right date span, units still available. Expired authorizations, exhausted units, and visits scheduled against the wrong service line all pass EVV checks and then die at the payer.
5. Schedule mismatches. Aggregators compare the verified visit to the schedule on file. A visit worked at a different time than scheduled — a swap, an early start, a rescheduled day nobody updated — can flag even though the care was delivered exactly as authorized.
6. Rounding and unit thresholds. Medicaid personal care generally bills in 15-minute units, and states set rules for how verified minutes convert to billable units. A caregiver who clocks in a few minutes late and out a few minutes early can verify one unit short of the schedule on every visit — a loss that pays cleanly, flags nothing, and compounds across a census.
7. Timely filing. Not a failure of verification but the deadline on fixing one. Every state sets a filing window; an exception that sits unworked past it converts from a receivable into a write-off. Filing windows are the reason exception backlogs are more urgent than they look.
States implemented EVV differently. Some run a single mandated system every agency must use; others run an aggregator model — Sandata, HHAeXchange, Netsmart, and AuthentiCare are common — where agencies may keep their own EVV vendor and feed the state system. Matching tolerances, rounding rules, manual-edit policies, and filing windows are all state-specific, and a fix that works in one state can be non-compliant in the next. Any serious recovery effort starts by reading the state's EVV specifications, not the vendor's brochure.
Agencies that keep EVV losses small tend to do the same few things:
— Work the exception queue daily, not at billing time, so fixes land well inside the filing window.
— Rank exceptions by root cause and fix the cause — one caregiver's phone, one member's geofence — instead of the same symptom every week.
— Reconcile verified time against scheduled time monthly, so rounding losses are visible.
— Track authorization end-dates and unit balances ahead of scheduling, not behind billing.
— Treat the remittance as the source of truth: every unit scheduled is either paid, in process, or explained.