Unverified Home Care Claims Draw Scrutiny in New York

Home care agencies billing New York Medicaid must confirm electronic visit records match every claim they submit.

Updated on Nov. 6, 2026 in Healthcare

Unverified Home Care Claims Draw Scrutiny in New York

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New York paid $14.5 billion in Medicaid claims without verifying that patients received the billed care, and did not activate a built-in system feature that would have blocked claims lacking matching electronic visit verification records. The findings, drawn from a state comptroller's review, bear on how home care and Medicaid providers statewide must document their visits.

Why it matters

Federal rules require Medicaid claims for certain home care services to carry a matching electronic visit verification record, so unverified payments expose both the state and the providers billing it to recoupment and oversight risk. Other states are already tightening their own claim controls, raising the compliance bar for agencies operating across state lines.

The comptroller's review covered $14.5 billion in Medicaid payments, of which only a little more than half of care was verified during the period examined. Nearly $10 million went to home care visits billed while patients were hospitalized, and about $1.2 billion in premiums covered people living outside New York.

The players

New York State Office of the State Comptroller

The state's independent fiscal watchdog, which audits state agencies and programs, including Medicaid spending and payment controls.

New York State Department of Health

The state agency that administers Medicaid, setting payment rules and overseeing providers, including home care agencies.

Missouri Department of Social Services

The state agency running Missouri's Medicaid program, which began automatically denying some mismatched claims this spring.

Texas Health and Human Services Commission

The state agency administering Texas Medicaid, which uses a system that rejects claims with mismatched codes.

Illinois Department of Healthcare and Family Services

The agency administering Illinois Medicaid, which is targeting a 75% verification compliance threshold with training and possible penalties.

The details

New York had a system feature designed to block Medicaid claims that lacked a matching electronic visit verification record, but the state did not turn it on. Without that check, claims flowed through for home care visits that could not be matched to documented care, including visits billed during hospital stays and visits lasting less than eight minutes. The review also tied more than $500 million in costs to address changes affecting more than 155,000 people, and another $375 million to the state Department of Health not reviewing federal matching data.

Missouri began automatically denying some claims this spring.
The comptroller's review covered a period that ended before only a little more than half of New York's care was found verified.

Market Landscape

The federal electronic visit verification requirement for Medicaid home care services sets a common standard that states are now enforcing through automated claim rejection, as Missouri and Texas have done. New York's inaction places it out of step with that trend, while Illinois is moving toward a 75% compliance threshold backed by possible agency penalties.

Home care agencies and providers billing New York Medicaid should confirm that every claim has a matching electronic visit verification record before submission. Operators with out-of-state patients or address changes should review billing records, since those categories drove significant costs in the findings.

The takeaway

Operators should treat electronic visit verification matching as a billing control to audit now rather than wait for enforcement. Reviewing visit records against claims for hospitalization dates and short visit durations is a practical step to take before a payer does it for you.