Medicaid home care denials run 10–15% industry-wide. At 30 patients submitting 400–500 claims a month, that's 40–60 denials. Each one requires 30–50 minutes to rework. Most agencies work about a third of them. The rest become visits that happened, caregivers who showed up, care that was delivered — and revenue that never arrived.
Every Medicaid denial has a specific reason code. Most agencies see the same reasons recurring month after month — the same EVV exceptions, the same authorization mismatches, the same service code errors. They're recurring because they're being caught after submission rather than before it. The denial code is the symptom. The missed pre-submission check is the cause.
The Electronic Visit Verification record doesn't match what was billed — location discrepancy, clock-in time off, wrong patient, missed check-out. The care happened. The record doesn't match. The claim gets denied. EVV exceptions that aren't resolved before the billing deadline become EVV mismatches in the submitted claim.
Preventable pre-submissionThe patient's prior authorization had lapsed at the time of service, or the service exceeded the authorized hours for the period. Common when authorization renewal is delayed, when the agency doesn't track authorization expiration dates, or when scheduling exceeds the authorized amount without a system catching the overage.
Preventable pre-submissionThe service code billed doesn't match the authorized service, the payer contract, or what the caregiver actually provided. Service code errors require knowing the correct code for each payer, each service type, and each authorization — payer-specific rules vary significantly and change on MCO contract cycles.
Preventable pre-submissionThe caregiver providing service had a lapsed certification — expired CPR, background check not renewed, training hours not current. Medicaid will not pay for care delivered by a caregiver who wasn't credentialed to provide it at the time of service. The denial is retroactive — the care already happened.
Preventable pre-submissionThe service billed doesn't match the patient's documented care plan. Medicaid pays for authorized services that match the care plan — if the plan says personal care assistance and the visit documentation describes skilled care, or vice versa, the claim doesn't align with the authorization. Care plan mismatches often surface as denials rather than being caught in documentation review.
Preventable pre-submissionThe claim was submitted after the payer's timely filing window — typically 90 days to one year from the date of service. Once the timely filing deadline passes, the denial is permanent. There is no appeal. Agencies with large, unworked denial piles run the risk of losing older claims to timely filing while working newer ones. The oldest claims expire quietly.
No recovery after deadlineClaims Drain has two cost components: the cost of reworking denials that do get worked, and the permanent revenue loss from denials that don't. Most agencies focus on reducing the denial rate. The larger lever is the rework rate — what percentage of denials get worked, at what cost, and how many fall through before the timely filing window closes.
Every denial was a preventable error at some point before submission. The reason pre-submission review reduces Claims Drain is not that it finds different errors — it's that it finds the same errors at a point where fixing them takes minutes instead of hours, and where the revenue is still recoverable.
100+ agencies. 73% average revenue growth. No added back-office hires. Pre-submission claim review is part of what moves the needle — not by reducing the volume of claims, but by catching the errors that would have become permanent revenue losses before they leave the agency.
Billing software shows you what was denied after it was denied. CareBravo reviews each claim before submission to catch the errors that would cause a denial. The difference is the sequence: find the error before it leaves, not three weeks after it comes back. Your billing software's denial report is a list of things that already went wrong. CareBravo's pre-submission review is what prevents the list from growing. Both exist — but only one stops the revenue from leaving in the first place.
Yes, most Medicaid and MCO denials can be appealed within specific windows — typically 30 to 90 days from the denial date, depending on the payer. The appeal process requires identifying the specific denial reason, correcting the error, and submitting with supporting documentation. Some denial types — credential gaps, timely filing, certain authorization issues — have limited or no appeal path. CareBravo's billing function works denials for agencies on the appropriate tier, including MCO-specific appeal processes that most office staff aren't trained to navigate.
The most common EVV denial is a GPS location mismatch — the caregiver's check-in records a location that doesn't match the patient's service address. This happens when a caregiver checks in from a car in the parking lot, when GPS signal is poor inside a building, or when the patient has moved and the address in the system hasn't been updated. Preventing it requires resolving EVV exceptions within the billing cycle window — which means catching them within days of the visit, not weeks. CareBravo's EVV compliance function flags exceptions as they occur and tracks resolution before the billing deadline.
Neither, in the traditional sense. CareBravo delivers billing as a function — pre-submission review, EVV exception management, denial follow-through, MCO-specific appeal processes — as completed work. It is not software your team operates to produce billing output, and it is not a third-party billing company that processes claims in isolation from your other operational functions. Because billing connects to scheduling data, EVV records, authorization status, and caregiver credentials in the same system, the pre-submission check is comprehensive rather than operating on a data export. The integration is what makes the review accurate.
The estimate shows you the pattern for your patient count. CareBravo's diagnostic review shows you the precise figure on your real claims history — how many denials, what reasons, what the unworked remainder costs. You see the number before you decide anything.