Per diem up $47. $3.1M recovered across three buildings.
A Southeast skilled nursing group, three 120-bed buildings, was leaking cash on four paths at once: PDPM case-mix understated on the 5-day MDS, Part A benefit-exhaust days never billed to Part B, consolidated billing collisions paid twice, and Medicare Advantage authorizations tracked in binders. One integrity engine closed all four.
The situationFour leak paths. One census. Zero shared visibility.
The 5-day MDS understated the resident.
- → NTA comorbidities missing, avg 2.1 points short
- → Section GG function scores defaulted, nursing group misassigned
- → Zero interim payment assessments filed when acuity changed
Billing stopped where Part A stopped.
- → 1,900 benefit-exhaust days, no Part B claims ever filed
- → Outside suppliers hit CO-109 walls, then invoiced the SNF
- → No pre-bill consolidated billing screen at any building
Authorizations lived in binders.
- → Auth-related denial rate 14% of MA revenue billed
- → Concurrent review dates missed, stays cut short on paper
- → Three buildings, three spreadsheets, no expiry alerts
Why now · policy contextThe rules this engagement runs against.
CMS finalized a 3.2 percent net payment update for FY2026, roughly $1.16 billion in aggregate Part A payments to SNFs (CMS-1827-F). Every dollar of that update flows through PDPM case-mix, so an understated MDS discounts the rate increase too. Source: cms.gov SNF PPS.
PDPM pays five case-mix-adjusted components (PT, OT, SLP, nursing, NTA) plus a non-case-mix component. NTA pays at 3x for days 1 through 3, and PT/OT step down 2 percent every 7 days after day 20, so early MDS accuracy is worth the most. Source: cms.gov PDPM.
During a covered Part A stay the SNF is responsible for nearly the full service bundle under consolidated billing, with defined exclusions (cms.gov SNF CB). Meanwhile more than half of eligible Medicare beneficiaries are enrolled in Medicare Advantage (medpac.gov), which puts most SNF admissions under plan-managed authorization.
The money mapWhere $3.4M was trapped. Where $3.1M came back.
| LEAK PATH | MECHANISM | TRAPPED | RECOVERED | SHARE |
|---|---|---|---|---|
| PDPM case-mix integrity | NTA and GG under-capture on the 5-day MDS; missed IPAs. $520K retro corrections plus ~$720K annualized run-rate ($47/day × 15,330 Medicare A days). | $1.36M | $1.24M | 40% |
| MA authorization tracking | $610K auth-related denials overturned on appeal; $220K in level-of-care downgrades prevented by concurrent review discipline. | $0.92M | $0.83M | 27% |
| Part A / Part B separation | $380K of benefit-exhaust days billed to Part B for the first time; $240K of post-Part-A therapy moved onto Part B claims. | $0.68M | $0.62M | 20% |
| Consolidated billing compliance | $150K of double-paid supplier invoices recouped or offset; $260K of CO-109 rejections re-routed and billed correctly. | $0.44M | $0.41M | 13% |
| Total · 3 buildings | $3.40M | $3.10M | 100% |
FIGURES ARE AN ANONYMIZED ARCHETYPE, ILLUSTRATIVE AND INTERNALLY CONSISTENT. SHARES ARE OF RECOVERED DOLLARS, ROUNDED.
PDPM component waterfallFrom $565 to $612. Component by component.
The fix · workflowFour gates. Every claim passes all four.
Denial taxonomy · 90-day baseline sampleWhat $1.9M of denials actually said.
| PATTERN | TYPICAL CODES | ROOT CAUSE | 90-DAY $ | SHARE |
|---|---|---|---|---|
| MA authorization | CO-197 · CO-15 | No auth on file, auth expired mid-stay, concurrent review missed | $740K | 39% |
| Consolidated billing collision | CO-109 · A1 | Supplier billed Part B for bundled service during covered Part A stay | $310K | 16% |
| Benefit exhaust / A-B crossover | CO-96 · PR-119 | Claims filed to Part A past day 100, no Part B lane existed | $290K | 15% |
| PDPM assessment defects | CO-16 · N329 | Late or defaulted 5-day MDS, HIPPS mismatch, default-rate days | $260K | 14% |
| Eligibility and other | CO-27 · PR-31 | Coverage terminated, MSP conflicts, demographic mismatches | $300K | 16% |
| Total · 90-day sample | $1.9M | 100% |
What the dashboard showsEvery MA auth. Every clock. One screen.
KPI movement before vs current.
We thought PDPM was a rate problem. It was a documentation problem wearing a rate costume. The chart already justified $612. We were billing $565.
The 90-day installFour gates live in thirteen weeks.
Baseline audit
MDS-to-UB-04 crosswalk on 12 months of Part A stays. Denial taxonomy built from CARC/RARC. $3.4M trapped cash mapped to four lanes.
PDPM integrity
MDS coordinators retrained on GG and NTA capture. IPA triggers defined. Retro corrections filed inside timely filing. Per diem starts climbing.
A/B router + CB screen
Benefit-exhaust router live, 1,900 unbilled days queued to Part B. Pre-bill consolidated billing screen deployed at all three buildings.
MA auth gate live
Shared auth tracker replaces binders. Claim gate enforced. Appeal templates per plan. Denial rate on a glide path from 14% to 3%.
The binder system died in week eleven. Nobody misses it. The tracker tells us three days before a plan does.
OutcomesBefore. After. In numbers.
Capability stackWhat the four gates actually run on.
Common questionsFrequently asked: SNF PDPM recovery.
What is PDPM case-mix integrity?
What is SNF consolidated billing and why does CO-109 keep appearing?
How does Part A versus Part B separation leak cash?
Why do Medicare Advantage authorizations need their own tracker?
Why anonymize the client?
What does the free audit look like for a SNF group?
Want the same audit applied to your buildings?
A free 30-day audit. Send 90 days of remittance data, your MDS 5-day extract with HIPPS codes, your Part A census with benefit-exhaust dates, and your MA auth log. We return a 4-page written audit covering PDPM component gaps, consolidated billing exposure, unbilled Part B days, MA auth risk, and a 90-day fix plan. Yours to keep. No SDR follow-up.