PDPM is a payment system. It’s also an operations system.
Skilled nursing reimbursement runs on the MDS. Get the assessment timing wrong, miss an interim payment assessment, fail a triple-check, and the consequences are immediate. We run SNF revenue cycle the way SNF reimbursement actually works. clinical, financial, and admissions in one room.
every claim
Six functions tuned for PDPM-era nursing.
PDPM is five payment components. PT, OT, SLP, Nursing, NTA. that all read the MDS differently. The teams that win are the ones whose admissions, MDS coordinators, and billers operate as one workflow.
PDPM optimization & MDS coordination
5-day, IPA, and discharge assessments aligned to clinical reality and PDPM scoring. NTA score, SLP comorbidities, and section GG functional scoring captured accurately the first time.
Triple-check pre-bill
Every Part A claim passes a triple-check before submission: clinical (MDS, supporting documentation), MDS (HIPPS code, ARD), billing (claim, modifiers, dates). If any of three says no, the claim doesn’t go.
Medicaid pending case management
Application started day of admission. Documentation gathered, lookback handled, redeterminations tracked. Admissions packet built so the application is filed cleanly, not patched together months later.
Part A & Part B billing
Part A SNF claims with HIPPS, occurrence codes, and value codes correct. Part B therapy and ancillary billing under the consolidated billing rules. Bad-debt logs maintained for cost-reporting.
Census-driven A/R management
Aging worked by payer mix, not flat. Medicare Advantage authorization and level-of-care extensions managed proactively. Private-pay collections handled with the family relationship intact.
Cost report & survey support
CMS-2540 prep with revenue, statistical, and bad-debt data assembled year-round. F-tag and FFS audit support: documentation pulled, samples assembled, narrative drafted with the administrator.
Six structural leak points.
NTA score under-captured
Comorbidities present in the chart but not coded on the MDS. NTA component under-paid for the entire stay.
IPA missed
Significant change in condition not captured with an IPA. Reimbursement keeps tracking the original assessment.
Medicaid pending stalls
Application not started until census drops. Months of care delivered, no payment, lookback documentation gone.
MA authorization lapses
Continued-stay review missed; level-of-care drops or denial issued. Skilled days lost.
Triple-check skipped
HIPPS code on claim doesn’t match MDS submitted. Audit risk silent until ADR arrives.
Bad-debt log missing
Medicare bad debt not tracked claim-by-claim. Cost-report deduction left on the table.
Five phases. Same partner.
MDS & PDPM read
90 days of MDS submissions reviewed. NTA, SLP comorbidity, section GG accuracy assessed. Triple-check audit.
Pending & auth audit
Medicaid pending census reviewed. MA authorization calendar built. Bad-debt log reconstructed.
Cutover
SNF bench assigned. Triple-check installed as pre-bill discipline. Pending case manager embedded.
First survey-ready quarter
First quarter with triple-check, full Medicaid pending pipeline, MA auth calendar, bad-debt log live.
QBR + cost-report check
Senior partner walks scorecard. CMS-2540 readiness reviewed. Survey posture confirmed.
Six SLAs. SNF-specific.
| METRIC | TARGET | WHY IT MATTERS |
|---|---|---|
| Triple-check pass rate | 100% | Every Part A claim passes clinical / MDS / billing sign-off before submission. Non-negotiable. |
| MDS submission timeliness | 100% | 5-day, IPA, discharge submitted within CMS window. No late penalties. |
| Medicaid pending cycle | ≤ 90 days | Application to approval, median. Lookback delays pursued. |
| MA continued-stay auth | 98%+ | % of authorized days where the next continued-stay review was completed before expiry. |
| Days in AR (dollar-weighted) | 40-50 | SNF-typical range. Medicaid-pending mix-adjusted. |
| ADR / TPE response | ≤ 30 days | Documentation requests answered within window with clinical narrative attached. |
SNF revenue cycle is clinical, MDS, and billing in one room.
Most billing companies treat SNFs like physician practices with longer stays. They aren’t. Reimbursement reads the MDS, the MDS reads the chart, the chart reads the care plan. We staff SNF accounts with senior leads who’ve worked the floor. MDS coordinators, administrators, business office managers. not generic billers learning PDPM on your dollar.
SNF-fluent senior, triple-check pre-bill, pending pipeline.
- Clinical-first senior. MDS coordinator or DON background.
- Triple-check non-negotiable. clinical, MDS, billing align before submission.
- Medicaid pending pipeline. started day of admission, redeterminations tracked.
- MA auth calendar. continued-stay reviews never lapse silently.
- Cost-report ready. revenue, stat, bad-debt tied year-round.
Four monthly outcomes.
Get a free triple-check + pending audit.
Send us a sample of last month’s Part A claims and your current Medicaid-pending census. We’ll send back a 4-page diagnostic on PDPM capture, triple-check posture, and pending pipeline risk. No obligation.