What billing mistakes trip up Medicaid home care most, and how do we avoid them?

Short answer:
The usual culprits are expired or missing authorizations, EVV and claim data that do not match, wrong codes or modifiers, services billed for someone who was not eligible that day, duplicate submissions, and filing after the plan’s deadline. Each one slows or blocks payment, but all of them are preventable with simple checks.

What goes wrong (and how to prevent it):

• Authorizations
  Problem: Claim falls outside approved dates or hours.
  Fix: Use an auth tracker with alerts for expiring hours and end dates. Stop claims that are out of scope.
• EVV mismatches
  Problem: Time in and out, caregiver ID, or service code in EVV does not match the claim.
  Fix: Reconcile visits to claims every day and require corrections before a claim can move forward.
• Codes and modifiers
  Problem: Wrong HCPCS, missing state modifier, or incorrect units.
  Fix: Maintain a payer and waiver cheat sheet. Lock templates by payer so the right code set is the default.
• Eligibility
  Problem: Member not eligible on the date of service.
  Fix: Run eligibility at scheduling and again before submission. Auto-hold claims when eligibility fails.
• Duplicates
  Problem: The same visit is billed twice after an edit or resubmission.
  Fix: Use unique visit IDs and deny any second claim with the same ID and date of service.
• Late filing
  Problem: You missed the plan’s window.
  Fix: Post payer-specific limits where staff work. Set weekly sweeps for unbilled visits older than 30, 60, and 90 days.

Pro tip: Do the checks before the claim leaves your system. A pre-submission gate that verifies authorization, EVV match, eligibility, codes, and filing window will prevent most denials.

If you want help putting this into practice, Paradigm can take over Medicaid billing workflows end to end, including EVV reconciliation, auth tracking, denial work, and payer reporting, so you get paid on time without the back-and-forth.

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