Navigating Medicaid Waiver Program Regulations

Navigating the complex regulations and oversight requirements of Medicaid waiver programs can be challenging. Agencies must ensure they are in compliance with both aggregator AND state guidelines to ensure timely payments.However, the complexities of compliance with both state and aggregator guidelines can create significant operational challenges. Navigating these regulations requires diligence, adaptability, and a strategic approach to ensure both compliance and efficiency.

Understanding the Oversight Landscape

Medicaid waiver programs are designed to provide home and community-based services (HCBS) as an alternative to institutional care. This is the first time Medicaid has provided coverage for long-term care in a homecare environment and these new programs have had lax oversight over the past because they waiver from the traditional Meidciad rules. States have struggled to ensure these services are in place and properly delivered as they save millions of dollars over state-funded institutionalized care, which is the alternative.

To improve oversight, Congress enacted the 21^st Century Cures Act that requires states to obtain electronic visit verification (EVV) for every visit paid for by Medicaid (which is a 50/50 split between the state and the federal government.) As states began to comply with the Act, they have all begun to require EVV as the first step to full-scale audits and hard-edit billing, which is the ultimate goal.

This oversight is being introduced to agencies in stages. The first step is to get all the agencies using EVV to document all of their visits. Then comes auditing of the clients and workers for compliance, and then on to visit audits. Visit audits ensure the EVV matches the claim, the services are within the authorization, and the services match the prescribed plan of care.

Agencies are responsible for staying informed about evolving regulations and ensuring that all processes align with these requirements. Aggregators, such as Sandata, Tellus, and HHAeXchange, are responsible for overseeing claims and ensuring compliance with EVV mandates.

Failure to adhere to their guidelines can result in denied claims, delayed payments, or even program exclusion. State agencies throughout the Country are auditing EVV data, comparing claims, and actively rooting out non-compliance. OIG and DOJ officials are also recovering payments made for non-complying visits, in some cases going back as far as three years!

Best Practices for Staying Compliant

• Invest in Compliance-Ready Software: Implementing a robust homecare management system like Compliance Plus can streamline scheduling, billing, payroll, and compliance tracking.
• Stay Updated on Regulatory Changes: Assign a senior manager to be in charge of compliance to keep abreast of evolving Medicaid and aggregator guidelines.
• Train Staff on Compliance Standards: Regular training ensures caregivers and administrative staff understand EVV requirements, documentation protocols, and fraud prevention measures. Remember – compliance rules change over time so what was okay to do last month may not be okay next month!
• Conduct Internal Audits: Proactively reviewing documentation and billing practices can identify potential compliance risks before they become costly issues. As an agency, you are responsible for ensuring your information is uploaded to the aggregator, matches your billing, and complies with the authorization and plan of care.

Regulatory compliance in Medicaid waiver programs is an ongoing challenge, but agencies that invest in the right technology, training, and oversight can minimize risks while ensuring sustainable operations. By staying proactive and adaptable, homecare providers can continue delivering quality care without the constant threat of compliance-related disruptions.

About the author: David Cole is a senior project manager for Compliance Plus. His background spans 35 years including having been a pioneer in the development of EVV, owner of several non-medical homecare agencies, and serving as the administrator for Interim Healthcare in Atlanta, Georgia. (www.davidscole.com)