Maine's Annual PCS Audit and the EVV Findings CMS Flagged in 2024

Title options:

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2. The Pend Queue Problem: How Maine's EVV Timing Rules Slow Down Your Cash Flow
3. Maine's Lifespan Waiver and What It Means for IDD Provider Billing

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Maine's personal care services environment operates under two layers of scrutiny that most other states don't combine: an annual audit of every PCS agency by OADS, and a federal program integrity review that CMS completed in June 2024 — and that identified specific concerns about Maine's EVV practices.

What CMS Found in 2024

In June 2024, CMS conducted a focused program integrity review of Maine's PCS program, assessing compliance with regulatory requirements covering provider oversight, documentation, and EVV. The review found that while Maine's EVV system — built on Sandata under an open model — meets federal requirements, CMS identified issues with how EVV data was being used for program integrity purposes. Specifically, CMS encouraged Maine to more actively leverage EVV data for analytics, outlier identification, and post-payment reviews to detect potential fraud, waste, and abuse.

The practical implication for providers: Maine DHHS is under federal pressure to sharpen its use of EVV data as a surveillance and audit tool. Agencies whose EVV compliance has been inconsistent — high manual entry rates, frequent exceptions, visits recorded outside expected locations — are more visible to program integrity reviewers as a result of that pressure.

The Annual Audit Reality

Independently of the CMS review, every PCS agency in Maine is subject to an annual OADS audit. These aren't targeted audits triggered by a specific complaint or claim flag — they're routine, covering personnel files, client records, and service billing records for all agencies, every year. Deficiencies found during an audit can result in recoupments and mandatory corrective action plans.

The combination of routine annual audits and CMS pressure to expand EVV-based program integrity means Maine providers are operating in a tighter compliance environment than the state's small size might suggest.

The Pend Queue Problem

Maine's claim processing has a specific EVV timing issue that creates cash flow risk even for compliant providers. Home health and hospice claims with dates of service on or after July 1, 2022, are subject to a claim pend edit when no matching EVV record is found. The pend period is a three-day recycle — but that can be longer than three calendar days depending on when in the week the claim was submitted. Claims enter and exit the pend queue daily as EVV records are matched.

For agencies with high visit volumes, even a 48-hour lag between when a caregiver clocks out and when the EVV record hits Sandata can move a significant number of claims into pend status. The fix is operational: enter EVV records in real time, not retrospectively.

The Lifespan Waiver Transition Ahead

Maine is in the final stages of developing a new Lifespan HCBS Waiver for individuals with IDD and Autism — expected to open for enrollment in 2025. The Lifespan Waiver will replace the existing Section 21 and Section 29 waivers, which will close to new enrollment once Lifespan launches. OADS also implemented Evergreen, a new case management information system, in 2024 to support the transition.

For current Section 21 and 29 providers, this means a billing structure change is coming. Service definitions, authorization processes, and rate methodologies are being updated through an ongoing rate study. A rate study released at a public hearing in April 2025 will establish new rates for Lifespan and updated rates for existing IDD waivers. Providers who aren't tracking the Lifespan rollout will be in the same position as Maryland providers during the Community Pathways consolidation — catching up to billing changes after they've already gone live.

What Providers Should Do Now

Audit your Sandata compliance and identify any EVV records that are being entered retrospectively rather than at the time of service. Review your OADS audit readiness — personnel files, client documentation, and billing records should be current and accessible. And begin tracking the Lifespan Waiver timeline now so billing system updates, staff training, and authorization workflows are in place before enrollment opens.

Maine is a smaller Medicaid market, but the compliance obligations are full-size.