New York home care margin recovery: find the hours you delivered but never billed clean.
You are already delivering the care.
In New York, the money leaks in the gap between what the plan authorized, what your aides delivered, what you billed to eMedNY, and what actually got paid. Reeve is a free, read-only Margin Review that lines those four columns up side by side and shows you every place they disagree, with the record attached.
New York home care runs on four numbers that are supposed to agree and quietly do not.
Most New York personal care and home health hours are authorized by a Managed Long Term Care plan, a mainstream Medicaid Managed Care plan, or through a fiscal intermediary under CDPAP. The authorization is a ceiling: a number of hours or units per member, per week, under a specific service and rate code. Personal care rides on codes like T1019 and T1020, and the unit is the trap: eMedNY bills New York personal care on the UB-04 and says partial hours of service must be rounded to the nearest whole hour. A twenty minute visit is billed as zero hours and a ninety minute visit as two. Reeve applies that rounding to your delivered hours before it compares them to anything, because a raw minute count read against whole hour billing manufactures a shortfall on every short visit and an overbill on every long one.
Your aides show up and the visit gets captured through Electronic Visit Verification. New York runs a Choice Model, so you pick your own EVV vendor, but every Medicaid visit has to flow to the New York State EVV Data Aggregator operated through eMedNY. Six data elements have to land: the date, the start and end time, the service type, the caregiver, the member, and the location.
You submit the claim to eMedNY. New York holds fee-for-service claims to a 90-day timely-filing window from the date of service. Miss it and you need one of the recognized delay-reason codes to get the claim in, and even those run out at the two-year outer limit, after which the claim is not payable at all. Managed care and MLTC run on a different clock: New York Insurance Law 3224-a(g) gives a participating provider 120 days from the date of service to submit the claim to the plan, https://www.nysenate.gov/legislation/laws/ISC/3224-A.
The plan or eMedNY adjudicates and remits. But eMedNY does not currently match the EVV record to the claim at initial adjudication, so your EVV data and your paid claims drift apart with nothing forcing them back together.
The money does not leak in any one column. It leaks in the gaps between them, and in New York that gap cuts both ways: delivered visits captured in EVV that never turned into a clean paid claim, and paid claims with no matching EVV record that are clawback exposure waiting to happen.
- 01Delivered and verified in EVV, but no matching claim in eMedNY remittance.
- 02Paid claims with no matching EVV record on file, exactly what the state is auditing today.
- 03Delivered hours billed below the authorized ceiling.
- 04Visits continuing past an expired authorization end date.
- 05Delivered visits aging toward the 90-day timely-filing wall.
Every number is illustrative and synthetic, built to show the method, not results from any real agency. Because your own export may not carry a rate for every code, findings on this page are expressed in hours, units, and records to check against your own rate sheet.
42 personal care visits over one closed month have a complete EVV record in your system but no matching T1019 claim line in eMedNY remittance. Roughly 30 whole hours after New York's nearest whole hour rounding, sitting delivered and unbilled. 31 of the 42 are still inside the 90-day window and billable today. 11 have aged past 90 days and would need a valid delay-reason code or are lost.
On 14 members, delivered and EVV-verified hours came in under the plan authorization, and billed units came in under delivered. Example member: authorized 25 hours per week, delivered 25 after rounding, billed 22. That is 3 whole hours per week across 14 members. Records attached so you can check each against your contracted rate.
67 paid personal care claim lines have no corresponding record in your EVV export for the same member, date, and service window. Under today's rules eMedNY paid them anyway. Each one is a repayment risk if the state matches EVV to the claim retroactively. Flagged to verify or correct now, not to bill.
On 9 members, EVV shows visits continuing 6 to 19 days after the plan authorization end date, with no renewal on file. Delivered hours past an expired auth do not pay clean and invite denial or takeback. Reeve lists the member, the last authorized date, and the count of post-lapse verified visits.
23 delivered, EVV-verified visits are between day 76 and day 89 from date of service and not yet billed. Inside the 90-day window today. Reeve ranks them by days remaining so the ones about to age out get worked first.
Why an annual audit or the EMR alone misses this in New York.
Your EMR is very good at running one visit forward: schedule it, verify it, drop the claim. It is not built to look backward across authorized, delivered, billed, and paid at the same time and tell you where those four columns stopped agreeing. It shows you the claim it sent. It does not reconcile that claim against the EVV record that should support it, because eMedNY does not force that match either.
That is the trap. Because New York pays many claims without matching EVV at adjudication, nothing in the normal flow ever tells you a delivered visit fell out or a paid claim is unsupported. It looks fine until an auditor pulls the thread.
And the clock is unforgiving. The 90-day filing window means a delivered visit you have not billed is not a someday problem, it is a this-quarter problem. An annual audit runs long after those visits crossed day 90 and became unrecoverable. The reconciliation has to happen on a closed period, monthly, while the window is still open. That is the job Reeve does.
A yearly look tells you what happened. Reeve shows you what is still recoverable, before an auditor does.
Plain answers, on the record.
Straight answers about how the Margin Review works in New York, what it touches, and what it will not claim.
Collect is money you never captured. Cover is money a payer can still take back.
Reeve reports the two separately and never adds them together, because only one of them is yours to go and get. The Margin Review reads both on your own export and costs nothing.
One pass over your own export, in your browser. The findings are yours to keep, with no obligation.
The recovery lane. Care you delivered and never billed, units short of what was authorized, lines paid under the published rate.
Everything in Collect, plus the exposure lane. Retired codes, authorizations at the end of their period, care delivered past what was approved.
Month to month, no annual contract. Read-only in every tier. Run the free review.
Try it yourself. Run a free Margin Review.
Run a free Margin Review on one closed month. You export the file, it opens in your browser, and you see every place your authorized, delivered, billed, and paid numbers stopped agreeing, with the record attached. No sales call required to see the finding.
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Read-only. Reeve reads your data. It does not write to your EMR, does not file or change a claim, does not move a dollar.
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Names coded on your machine. The review runs in your own browser and strips names, addresses, and Medicaid numbers locally, before any analysis.
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Your file is processed in your browser, and no name is written into any output. No client-identified record is uploaded anywhere. You keep your data. You keep the finding, whether or not we ever work together.
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No testimonials and no automated overnight scanning. It is a tool you run yourself on data you already have.
Any dollar figures in examples are illustrative and synthetic, method rather than results. Reeve never invents a rate; dollars come from the rate on your own export or the rate your own remittances actually paid most often.