In conversation with Kelli Hansen on Protecting Operational Control in Medicaid-Driven Home Care

Home care agencies running STAR+PLUS, MDCP, CLASS, and PDN caseloads together are managing different sets of authorization and billing rules under one roof.

A lot of what separates agencies that protect their revenue from agencies that quietly bleed it out has little to do with care delivery. It starts with how they manage the authorization queue and the authorization cycle. And the systems they use to catch losses before they become a problem.

Regulatory scrutiny is increasing. Reimbursement models continue to shift. Agencies that stay ahead of both. They are treating authorization management as a separate discipline. And not as an afterthought to scheduling.

To shed light on this, we interviewed a home care industry expert to share her perspective on protecting revenue and care quality in Medicaid waiver programs.

Let’s dive into the conversation about protecting revenue and operational control in Medicaid waiver programs.

Question 1. With such a wide mix of programs (STAR+PLUS, MDCP, CLASS, PDN), where do agencies most often lose operational control—and how can they fix it early?

In my experience, agencies tend to lose operational control over insurance authorizations compared to discipline visits scheduled and completed. If there is no solid procedure and no designated employee responsible for managing this process, operational breakdowns tend to occur. If not managed properly, this area alone can result in significant profit loss for an organization when authorization requests are made late, denied, or missed while discipline visits continue and no authorization is in place; the company can’t recoup the loss.  Too many of those, and the ability to recover from such a loss diminishes over time.

Organizations can fix this operational control by establishing a continuous plan to follow through on authorization reviews and submissions early enough to secure approvals, placing visits on hold if approvals are delayed, and staying consistent with ongoing patient care and changes across the wide mix of programs and authorization requirements to prevent delays or denials.

Question 2. In large Medicaid-driven operations, what are the most common breakdowns between authorizations, scheduling, and billing that impact revenue?

Patients are scheduled too far in advance, and authorizations expire and are not renewed expeditiously.  Billing codes may change over time due to each insurance provider’s program requirements, and if communication with the organization is missed, it can result in unnecessary denials and additional time spent submitting appeals that may not be overturned or approved. Several insurance programs will not permit retro authorization requests. 

If a patient continues to be seen by a discipline, for example, Skilled Nursing 3x/week for wound care management, and the authorization renewal was missed for an extended period of time, the organization may not be able to bill for all the nursing visits performed, essentially leading to a huge loss in revenue that is missed.

Question  3. Serving 600+ clients across Texas is no small task—what systems or workflows have helped you maintain consistency in care quality at that scale?

The introduction of EHR in an organization was significant for managing a large number of clients, providing a centralized location for documentation and daily task management. The use of Smartsheet played an important role in the division of employee-assigned tasks, helping the division stay up to date on day-to-day tasks associated with each aspect of patient management. Team communication is always crucial in an organization, using Microsoft email, Teams, and OneDrive to stay connected.

Question 4. How do you approach staffing challenges differently when managing both PAS/PCS and higher-acuity services like PDN?

Typically, an organization will divide these two services into separate management departments. The department tasked with staffing PAS/PCS is more focused on hiring and assigning specific hours for that patient to cover the authorized hours, and is not necessarily focused on the skill sets required for staffing PDN cases.

The organization places job postings specific to location and skills needed at the time PDN case referrals are received for staff in higher-acuity services, aligned with a specific patient’s needs and schedule, since you cannot predict what will be needed, as each case is different from many PAS cases. It is a much longer process to staff PDN cases and find the right fit for individual patients and their needs, especially in rural areas without nearby accessible resources or in less-populated areas where staffing is less available.

Question 5. As we move into 2026, what shifts do you expect in Medicaid, MCO expectations, or care delivery models that agencies should prepare for now?

Under the current presidency, there is a focus on reducing government spending and on funding cuts. Due to rampant past fraud in healthcare, particularly in Medicaid/Medicare programs, the focus has increased on ways to prevent such fraud. Regulatory standards are now requiring caregivers/disciplines to clock in and out in the homes of patients to prove care was performed to prevent fraudulent charges for ‘fake patient profiles,” etc. 

Compliance standards have been set with the expectation that agencies will achieve at least 80% compliance. PDGM- Patient Driven Groupings Model is at the forefront, using 30-day periods as a basis for payment. This allows for payment adjustments based on case-mix groups and different subgroups, focusing on:

In particular, 30-day periods are placed into different subgroups for each of the following broad categories:

• Admission source (two subgroups): community or institutional.
• Timing of the 30-day period (two subgroups): early or late.
• Clinical grouping (twelve subgroups): musculoskeletal rehabilitation, neuro/stroke rehabilitation, wounds, medication management, teaching, and assessment (MMTA) – surgical aftercare, MMTA – cardiac and circulatory, MMTA – endocrine, MMTA – gastrointestinal tract and genitourinary system, MMTA – infectious disease, neoplasms and blood-forming diseases, MMTA – respiratory, MMTA- other, behavioral health, or complex nursing interventions.
• Functional impairment level (three subgroups): low, medium, or high.
• Comorbidity adjustment (three subgroups): none, low, or high based on secondary diagnoses.

Question 6. Where do you see AI realistically making an impact in home care—especially in areas like scheduling, compliance tracking, or utilization review?

I am already seeing AI being utilized in the Medicare arena for scheduling outpatients appropriately based on authorization, ordered disciplines, and frequency for a 14-day period. I anticipate continued development of AI to use more checkpoints, avoiding overscheduling past authorizations and preventing organizational revenue losses. I anticipate AI being utilized for compliance tracking across episodes, employee compliance, patient compliance, Quality Assurance compliance, and visit utilization. 

I envision AI being used to develop a standardized recommendation for a set number of visits based on symptom criteria, age of the patient, barriers to care, frequency of hospitalization, and other pertinent criteria to develop an overall standard recommendation for different diagnoses to act as a guide in developing plans of care and goals for meeting individual patient needs in expected timeframes.

In Conclusion

It’s important to note that protecting revenue for home care agencies (medicaid market) means protecting both care and the systems that support it. It’s no longer a base requirement but a necessity that agencies cannot afford to overlook. 

Kelli Hansen’s experience at Vital Caring Group points to a few things: disciplined authorization management, centralized systems, staffing built around what these programs actually demand. 

Agencies that catch authorization deadlines before they pass and keep pace with compliance, while holding people accountable, will be the ones protecting revenue and patients. 

Regulatory structures keep climbing, and the PDGM (payment model) continues to change. This indicates that operational structures for medicaid programs matter more than ever. AI can better support scheduling, compliance tracking, and utilization review along the way. However, it’s most likely that none of that can make up for the procedural rigor and follow-through this process needs.