Revenue Leak Audit
Bluebonnet Home Care (fictional) · data through 2026-10-20 · 8,705 EVV visits, 8,077 claim lines, 6,800 payment lines reviewed
Revenue you can still collect$8,879163 items
Compliance exposure to correct$7,06248 items
Already lost (past deadline)$3657 items
Alerts and data issues26authorizations and source data
Do this week: 6 visits about to pass the filing deadline
| Issue | Member | Plan | Date | Amount | Detail |
|---|---|---|---|---|---|
| Unbilled visit close to the filing deadline | Diaz Charles | Wellpoint Texas | 2026-07-21 | $62 | verified visit V40002134; 4 days left to file |
| Unbilled visit close to the filing deadline | Lopez Earl | Superior HealthPlan | 2026-07-28 | $57 | verified visit V40002659; 11 days left to file |
| Unbilled visit close to the filing deadline | Davis Mildred | Superior HealthPlan | 2026-07-24 | $53 | verified visit V40002347; 7 days left to file |
| Unbilled visit close to the filing deadline | Harris Maria | UnitedHealthcare Community Plan | 2026-07-21 | $53 | verified visit V40002163; 4 days left to file |
| Unbilled visit close to the filing deadline | Davis Carmen | Superior HealthPlan | 2026-07-30 | $44 | verified visit V40002752; 13 days left to file |
| Unbilled visit close to the filing deadline | Morales Mildred | Wellpoint Texas | 2026-07-25 | $31 | verified visit V40002400; 8 days left to file |
Where the money is leaking
| Type | Problem | Count | Amount | What to do |
|---|---|---|---|---|
| Revenue recoverable | Unbilled visit close to the filing deadline | 6 | $299 | Bill now; the filing window is about to close. |
| Revenue recoverable | Verified visit never billed | 25 | $1,289 | Add the visit to the next claim batch. |
| Revenue recoverable | EVV exception is blocking billing | 20 | $1,034 | Resolve the exception in the EVV system with a reason code and documentation, then bill. |
| Revenue recoverable | Billed fewer units than delivered | 10 | $128 | Submit a corrected claim (frequency code 7) for the missing units. |
| Revenue recoverable | Paid below the contracted rate | 10 | $26 | Dispute with the plan, citing the contracted rate in force on the date of service. |
| Revenue recoverable | Denied: claim did not match a verified EVV visit | 2 | $84 | Look up the match result in the state EVV portal, correct the visit (visit maintenance) or the claim, and send a corrected claim. |
| Revenue recoverable | Claim modifiers differ from the EVV visit: will deny as a service mismatch | 3 | $145 | Correct the claim to the visit's HCPCS modifiers, in the same order, before the plan adjudicates it (or send a corrected claim once it is denied). |
| Compliance exposure | Attendant paid below the state base wage | 1 | $120 | Raise the pay rate and pay the difference back to the start date. |
| Revenue recoverable | Denied: missing or invalid information (CARC 16) | 13 | $656 | Correct the data shown in the detail and resubmit. |
| Revenue recoverable | Denied: no authorization (CARC 197) | 54 | $3,194 | Request retro-authorization from the plan, then resubmit or appeal. |
| Revenue recoverable | Claim with no response from the plan | 5 | $1,307 | Check claim status (276/277 or portal); resubmit if the plan has no record. |
| Compliance exposure | Billed with no EVV visit on record | 4 | $180 | Find visit documentation; if none exists, void the line and refund. |
| Compliance exposure | Billed while the EVV visit is unverified | 5 | $295 | Resolve the EVV exception or void the line and refund. |
| Compliance exposure | Claim date does not match the EVV visit date | 6 | $326 | Submit a corrected claim with the EVV visit date. |
| Compliance exposure | Billed more units than the EVV visit supports | 8 | $106 | Submit a corrected claim and return the overpayment. |
| Compliance exposure | Same visit paid twice | 3 | $150 | Void the duplicate claim and return the payment. |
| Compliance exposure | Delivered units exceed the authorization | 4 | $2,961 | Request an authorization increase; stop scheduling above authorized units. |
| Compliance exposure | Services continued after the authorization ended | 3 | $2,244 | Request retro-authorization; hold billing for these visits until approved. |
| Revenue recoverable | Visit verified by the agency but rejected by the state EVV aggregator | 5 | $290 | Fix the visit in visit maintenance using the rejection code (see the EVV worklist), then bill it. |
| Revenue recoverable | Claim denied because the state EVV record does not match | 6 | $273 | Correct the visit in visit maintenance before the window closes, then submit an adjusted claim. |
| Revenue recoverable | Visit fixed in visit maintenance after the denial; adjusted claim never sent | 4 | $154 | Submit the adjusted claim (frequency code 7, payer claim number) now. |
| Compliance exposure | Caregiver worked an EVV visit but payroll shows no pay for it | 4 | $159 | Check the timesheet; pay the caregiver in the next run (wage-and-hour exposure). |
| Compliance exposure | Payroll paid for a day with no EVV visit | 3 | $122 | Find the visit record (without it the visit cannot be billed) or correct payroll. |
| Compliance exposure | Payroll hours differ from EVV hours | 5 | $106 | Reconcile the timesheet with the EVV visit; correct pay or the visit. |
| Compliance exposure | Over 40 hours in a week without full overtime pay | 2 | $294 | Pay the missing overtime premium (FLSA: 1.5x for hours over 40). |
| Alert | Authorized units will run out before the authorization ends | 4 | $5,211 | Request more units now, or adjust the schedule to fit the authorization. |
| Alert | Authorization expires soon with no renewal | 6 | $0 | Request the renewal now so services and payment are not interrupted. |
| Alert | Denied as a duplicate (CARC 18) | 5 | $0 | No money owed: the original was paid. Fix the resubmission process. |
| Revenue lost | Never billed and past the filing deadline | 3 | $150 | Check for a good-cause exception; otherwise write off and fix the process. |
| Revenue lost | Denied: past timely filing (CARC 29) | 4 | $216 | Appeal only with proof of an earlier on-time submission; otherwise write off. |
| Data quality | Source data problem (repaired or quarantined for this analysis) | 11 | $0 | Fix at the source system so it does not recur. |
Ready to file (after your approval)
The engine drafted 57 claims (29 new, 28 corrected) covering 167 lines, worth about $2,420 in additional payment. Nothing is sent until an authorized person at the agency signs the review sheet.
EVV worklist: 40 visits to fix ($2,046)
Soonest deadline first. Each row says what the state or the EVV system rejected, how to fix it, and what happens after the fix. The full list is in the workbook and evv_worklist.csv.
| Fix by | Problem | Member | Visit date | Code | How to fix | Then | Amount |
|---|---|---|---|---|---|---|---|
| 2026-10-31 | Claim denied because the state EVV record does not match | Gonzalez Maria | 2026-07-28 | SVC | Service code or modifier on the visit does not match the authorization. Correct the service on the visit, or get the authorization corrected. | After the fix: submit an adjusted claim (frequency 7) with the payer claim number. | $35 |
| 2026-11-03 | Visit fixed in visit maintenance after the denial; adjusted claim never sent | Chavez Yolanda | 2026-07-31 | Submit the adjusted claim (frequency code 7, payer claim number) now. | Already fixed: approve the drafted adjusted claim in the claim batch. | $35 | |
| 2026-11-04 | Billed while the EVV visit is unverified | Gutierrez Irma | 2026-08-01 | TIME | Clock-in/clock-out is missing or overlaps another visit. Add the missing time with a reason code and documentation in visit maintenance. | If it cannot be verified: void the claim line and refund. | $48 |
| 2026-11-05 | Billed while the EVV visit is unverified | Rodriguez Billy | 2026-08-02 | TIME | Clock-in/clock-out is missing or overlaps another visit. Add the missing time with a reason code and documentation in visit maintenance. | If it cannot be verified: void the claim line and refund. | $62 |
| 2026-11-06 | Claim denied because the state EVV record does not match | Lewis Eugene | 2026-08-03 | MID | Member Medicaid ID on the visit does not match the state record. Correct the member ID in the EVV system (visit maintenance), then re-export. | After the fix: submit an adjusted claim (frequency 7) with the payer claim number. | $62 |
| 2026-11-07 | Visit verified by the agency but rejected by the state EVV aggregator | Reyes Elizabeth | 2026-08-04 | SVC | Service code or modifier on the visit does not match the authorization. Correct the service on the visit, or get the authorization corrected. | After the fix: confirm the aggregator accepts it, then bill the visit. | $62 |
| 2026-11-11 | EVV exception is blocking billing | Davis Mildred | 2026-08-08 | TIME | Clock-in/clock-out is missing or overlaps another visit. Add the missing time with a reason code and documentation in visit maintenance. | After the fix: the visit turns verified; bill it. | $48 |
| 2026-11-13 | Claim denied because the state EVV record does not match | Johnson Irma | 2026-08-10 | TIME | Clock-in/clock-out is missing or overlaps another visit. Add the missing time with a reason code and documentation in visit maintenance. | After the fix: submit an adjusted claim (frequency 7) with the payer claim number. | $35 |
| 2026-11-15 | Claim denied because the state EVV record does not match | Anderson Betty | 2026-08-12 | NPI | Provider NPI/API or contract on the visit is not on file for this program. Fix the provider setup in the EVV system and re-export the visit. | After the fix: submit an adjusted claim (frequency 7) with the payer claim number. | $62 |
| 2026-11-15 | EVV exception is blocking billing | Flores Maria | 2026-08-12 | TIME | Clock-in/clock-out is missing or overlaps another visit. Add the missing time with a reason code and documentation in visit maintenance. | After the fix: the visit turns verified; bill it. | $40 |
| 2026-11-17 | Visit fixed in visit maintenance after the denial; adjusted claim never sent | Davis John | 2026-08-14 | Submit the adjusted claim (frequency code 7, payer claim number) now. | Already fixed: approve the drafted adjusted claim in the claim batch. | $31 | |
| 2026-11-20 | EVV exception is blocking billing | Johnson Eugene | 2026-08-17 | TIME | Clock-in/clock-out is missing or overlaps another visit. Add the missing time with a reason code and documentation in visit maintenance. | After the fix: the visit turns verified; bill it. | $62 |
| 2026-11-22 | EVV exception is blocking billing | Morales Alma | 2026-08-19 | TIME | Clock-in/clock-out is missing or overlaps another visit. Add the missing time with a reason code and documentation in visit maintenance. | After the fix: the visit turns verified; bill it. | $44 |
| 2026-11-23 | EVV exception is blocking billing | Chavez Yolanda | 2026-08-20 | TIME | Clock-in/clock-out is missing or overlaps another visit. Add the missing time with a reason code and documentation in visit maintenance. | After the fix: the visit turns verified; bill it. | $40 |
| 2026-11-25 | EVV exception is blocking billing | Williams Mildred | 2026-08-22 | TIME | Clock-in/clock-out is missing or overlaps another visit. Add the missing time with a reason code and documentation in visit maintenance. | After the fix: the visit turns verified; bill it. | $57 |
Authorizations running out early: 8
At the pace of the last four weeks, these members use up their authorized units before the authorization ends. Ask the plan for more units now.
| Member | Plan | Auth | Units left | Units/week | Runs out | Auth ends |
|---|---|---|---|---|---|---|
| Cruz Dorothy | Superior HealthPlan | PA26103 | -111 | 31.5 | used up | 2026-11-24 |
| Rivera Ramon | Superior HealthPlan | PA26200 | -278 | 80.2 | used up | 2026-12-02 |
| Hernandez Maria | Molina Healthcare of Texas | PA26068 | -80 | 23.2 | used up | 2026-12-10 |
| Lopez Thomas | Molina Healthcare of Texas | PA26004 | -204 | 58.5 | used up | 2026-12-17 |
| Martinez Evelyn | Superior HealthPlan | PA26210 | 205 | 32 | 2026-12-03 | 2027-01-18 |
| Gutierrez Willie | Molina Healthcare of Texas | PA26100 | 393 | 59.2 | 2026-12-05 | 2027-01-21 |
| Martin Luis | Superior HealthPlan | PA26110 | 204 | 29.2 | 2026-12-07 | 2027-01-26 |
| Gonzalez Ernesto | UnitedHealthcare Community Plan | PA26038 | 363 | 46.8 | 2026-12-13 | 2027-02-06 |
Payroll and the direct-care share
From 2026-06-22 to 2026-10-11, direct-care labor (wages $353,407 plus 14% taxes and benefits) was 94.2% of earned revenue ($427,728). Target: 80%. Payroll matched to EVV by client and day found 14 problems (4 caregiver worked an evv visit but payroll shows no pay for it, 3 payroll paid for a day with no evv visit, 5 payroll hours differ from evv hours, 2 over 40 hours in a week without full overtime pay).
Largest items
| Issue | Member | Plan | Date | Amount | Detail |
|---|---|---|---|---|---|
| Unbilled visit close to the filing deadline | Diaz Charles | Wellpoint Texas | 2026-07-21 | $62 | verified visit V40002134; 4 days left to file |
| Unbilled visit close to the filing deadline | Lopez Earl | Superior HealthPlan | 2026-07-28 | $57 | verified visit V40002659; 11 days left to file |
| Unbilled visit close to the filing deadline | Davis Mildred | Superior HealthPlan | 2026-07-24 | $53 | verified visit V40002347; 7 days left to file |
| Unbilled visit close to the filing deadline | Harris Maria | UnitedHealthcare Community Plan | 2026-07-21 | $53 | verified visit V40002163; 4 days left to file |
| Unbilled visit close to the filing deadline | Davis Carmen | Superior HealthPlan | 2026-07-30 | $44 | verified visit V40002752; 13 days left to file |
| Unbilled visit close to the filing deadline | Morales Mildred | Wellpoint Texas | 2026-07-25 | $31 | verified visit V40002400; 8 days left to file |
| Delivered units exceed the authorization | Rivera Ramon | Superior HealthPlan | $1,223 | auth PA26200: 1387 units delivered vs 1109 authorized (2026-06-06 to 2026-12-02) | |
| Services continued after the authorization ended | Gonzalez Linda | Superior HealthPlan | $1,175 | S5125 authorization ended 2026-08-28; 45 visits since (26 already denied) | |
| Delivered units exceed the authorization | Lopez Thomas | Molina Healthcare of Texas | $898 | auth PA26004: 1017 units delivered vs 813 authorized (2026-06-21 to 2026-12-17) | |
| Services continued after the authorization ended | Miller Juan | Superior HealthPlan | $638 | S5125 authorization ended 2026-08-17; 27 visits since (18 already denied) | |
| Delivered units exceed the authorization | Cruz Dorothy | Superior HealthPlan | $488 | auth PA26103: 551 units delivered vs 440 authorized (2026-05-29 to 2026-11-24) | |
| Services continued after the authorization ended | Martin Betty | Molina Healthcare of Texas | $431 | S5125 authorization ended 2026-08-27; 22 visits since (10 already denied) | |
| Delivered units exceed the authorization | Hernandez Maria | Molina Healthcare of Texas | $352 | auth PA26068: 400 units delivered vs 320 authorized (2026-06-14 to 2026-12-10) | |
| Over 40 hours in a week without full overtime pay | 2026-08-10 | $162 | R. Dominguez: 64.5 hours in the week of 2026-08-10; 0 paid as overtime, 24.5 owed ($162.31 premium at $13.25/h) | ||
| Over 40 hours in a week without full overtime pay | 2026-08-10 | $131 | J. Ibarra: 58.75 hours in the week of 2026-08-10; 0 paid as overtime, 18.75 owed ($131.25 premium at $14.00/h) | ||
| Attendant paid below the state base wage | 2026-06-22 | $120 | T. Garza: paid $12.50/h for 240.5 hours from 2026-06-22 to 2026-10-11; the base wage is $13.00/h. Back pay owed: $120.25 (plus taxes and benefits) | ||
| Billed while the EVV visit is unverified | Moore Dorothy | Superior HealthPlan | 2026-06-22 | $75 | EVV status "Exception" (Caregiver not linked to member) on visit V40000014 |
| Billed while the EVV visit is unverified | Rodriguez Jose | Molina Healthcare of Texas | 2026-06-22 | $75 | EVV status "Exception" (GPS location mismatch) on visit V40000019 |
| Claim date does not match the EVV visit date | White Frances | Molina Healthcare of Texas | 2026-07-29 | $70 | EVV visit V40002691 on 2026-07-29; claim billed it as 2026-07-28 |
| Claim date does not match the EVV visit date | Gomez Charles | Wellpoint Texas | 2026-06-27 | $66 | EVV visit V40000401 on 2026-06-27; claim billed it as 2026-06-28 |
How this was produced
Every EVV visit was matched to the claims sent (837) and the payments received (835) by member, date and service code, then checked against authorizations, the state EVV aggregator records and payroll. The rules are fixed and repeatable; no AI is used to calculate any amount. Amounts use the contracted rates on file. The full list with source records is in the Excel workbook.
This report identifies items for review. It is not legal advice. Refunds of overpayments should be reviewed with the agency's compliance lead.