Wisconsin home care margin recovery.
You delivered the visits.
In Wisconsin, only the EVV-listed codes require EVV, state-plan personal care usually needs a prior authorization beyond the initial units, and Reeve has not verified a Wisconsin fee-for-service filing window against a primary source, so it does not state one. On Family Care, the Department of Health Services managed care organization contract sets the submission window in a band that runs from 120 days to 12 months from the date of service depending on the contract year and the plan, https://www.dhs.wisconsin.gov/familycare/mcos/index.htm, so read your own contract for the number. Reeve reads your own billing export, right in your browser, and shows you the authorized, delivered, billed, and paid columns side by side, so the gaps have a record attached.
Every dollar of personal and supportive home care in Wisconsin passes through four states of being, and they do not always agree.
The payer approved a number of units or days. In Wisconsin that is state-plan Personal Care under BadgerCare Plus and Medicaid, IRIS for self-directed members, or Family Care and Partnership for managed long-term care with Supportive Home Care. State-plan personal care generally requires a prior authorization beyond the initial units. The clock and the ceiling both live here.
The people who deliver the care worked the visit and it landed in Electronic Visit Verification. Wisconsin runs an open EVV model with Sandata as the state aggregator. Not every code is on the EVV list, so EVV applies to some services and not others. Where EVV applies, the visit becomes an accepted Sandata transaction, or it does not.
A claim went out to the correct payer with a Medicaid ID, date of service, NPI, and the right code for the program: T1019 per 15 minutes for state-plan personal care, T1020 per day inside Family Care, S5125 per 15 minutes and S5126 per day for Supportive Home Care, and 99509 per visit for live-in personal care. Getting the right code for the right program is where a lot of Wisconsin trouble hides.
The claim matched, cleared its other edits, and remitted. Or it hit a PA, EVV, or code mismatch and denied.
The leaks live in the gaps between those four columns, and Wisconsin has two rules that turn a gap into lost money: when the code is on the EVV list, the claim needs a matching accepted Sandata visit, and state-plan personal care usually needs a prior authorization beyond the initial units, so PA-versus-EVV-versus-claim mismatches deny even when the visit really happened. Family Care, Family Care Partnership and PACE carry a third rule that is money rather than paperwork: the ForwardHealth HCBS Minimum Fee Schedule, effective October 1, 2024, sets a minimum of $6.38 per fifteen minute unit for MCO directed supportive home care on S5120, S5125, S5130 and S5135, and $4.08 per unit for the worker on self directed supportive home care, https://www.forwardhealth.wi.gov/WIPortal/cms/page/managedcare/HCBSMinimumFee. Personal care T1019 is not on that schedule and carries no minimum. On a per diem code the minimum is $6.38 multiplied by the fifteen minute units of care and direct active supervision, so Reeve prices it only when the row states those units. The 2026 Family Care contract, Article VIII.D.29, also sets filing at no less than 120 days, so Reeve never calls a Family Care line barred before day 120.
- 01Delivered but never billed
- 02EVV-required code with no matching Sandata visit
- 03Prior authorization missing on state-plan personal care beyond the initial units
- 04Wrong code for the program, T1019 versus T1020, S5125 versus S5126, or 99509
- 05Aged out of a filing window the payer sets by contract
Every number is illustrative and synthetic. 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, never in dollars Reeve made up.
17 state-plan personal care claims paid clean this quarter where the accepted Sandata visit shows more delivered quarter-hour units than the claim billed. Example: a visit accepted for 13 units of T1019, claim billed 11. The claim matched and paid, so nothing flagged, but 2 units per visit across 17 visits is 34 units of delivered care that never turned into a claim line. Records attached, ready to check against your contracted rate.
14 claim lines where the code did not match the program. Example: T1019 billed on a Family Care day where T1020 per day was correct, or S5125 per 15 minutes billed where S5126 per day was correct. Eleven of the fourteen can be rebilled today with the correct code. The other three are past the clock.
9 state-plan personal care lines that carried delivery beyond the initial units without a matching prior authorization on file. 7 of the 9 carry a payer that publishes a filing window in its own contract, and Reeve lists them by date of service so you can read them against it rather than against a number Reeve invented. The 2 are exposure only.
3 members where delivered and accepted Sandata units exceed the authorized units on file across programs. This is not recoverable, and Reeve will not pretend it is. It surfaces separately as over-delivery, care the people who deliver it gave that was never authorized, so you can see the exposure and fix the auth going forward rather than quote it as money owed.
17 delivered-and-accepted Sandata visits with no matching claim found in the export, sorted by date of service and oldest first. Wisconsin is one of the states where Reeve holds no verified fee-for-service filing window, so it ranks these by age and names the payer on each rather than telling you which are gone. On Family Care lines the DHS managed care organization contract sets a window somewhere in the 120-day to 12-month band, so read the line against your own contract.
Why an annual audit or the EMR alone misses this.
A once-a-year audit looks back over twelve months. In Wisconsin the harder problem is that state-plan personal care, IRIS, Family Care, and Partnership each use their own codes and rules and the mismatch is easy to miss line by line. By the time an annual review names a wrong-code denial, the same code has been going out for months. The annual review is a scorecard. It arrives after the lines it grades are unbillable.
The EMR is not built to catch it either. Your EMR knows what it billed. Sandata knows what EVV-required visits were accepted. The PA record knows what was authorized beyond the initial units. The remittance knows what paid. Those four live in four places, and the mismatch is in the seams between them.
The gap only shows when you put the accepted Sandata transaction, the PA, the member's program with its correct code, the claim, and the remittance in the same view and read them together. That is the one thing Reeve does. It reads across the seam.
That is what Reeve reads for in Wisconsin: what Sandata accepted, what the authorization allowed, what you billed, and what actually paid, read side by side rather than audited for rate.
Plain answers, on the record.
Straight answers on how the Wisconsin Margin Review works, 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.
No sales call. No account to create. Export your data, open the review in your browser, and see your authorized, delivered, billed, and paid columns lined up in about the time it takes to read this page.
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Read-only. Reeve reads your export and does not write to your EMR, does not file a claim, does not move money.
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Names coded locally. Names and member identifiers are replaced with a coded reference in your browser before any analysis runs.
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Your file is processed in your browser, and no name is written into any output. No upload of identified data, no server holding your client list.
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Yours to keep. The findings are yours whether or not we ever work together.
Reeve reads your billing read-only and replaces its names with coded references before any math runs. Every example figure is illustrative and synthetic, method rather than results, and Reeve makes no guarantee of recovery.