A skilled nursing per diem is assembled, not quoted.
Under the Patient Driven Payment Model a facility is not paid a rate. It is paid six stacked components, five of them case-mix adjusted, almost all of them set by one assessment in the first eight days of the stay, and two of them moving on a published schedule from the day the resident arrives. Revenue integrity in a skilled nursing facility is the discipline of making that stack tell the truth, every day, for the whole benefit period.
Module 01 · the diagnosisThe rate is an output. Most buildings manage it like an input.
Ask a skilled nursing administrator what their Medicare Part A rate is and you will usually get a single number, an average per diem carried in a spreadsheet and compared month over month. That number is not a rate. It is the arithmetic residue of thousands of individual coding, assessment, and billing decisions made by clinicians who mostly do not know they are making pricing decisions. When the average moves, the building looks for a payer explanation. The explanation is almost always internal.
The Patient Driven Payment Model replaced volume of therapy minutes with resident characteristics as the driver of payment. That was the right change clinically and it was a structural change financially, because it moved the revenue control point out of the therapy department and into the assessment. Under the prior model a facility could influence payment after admission by delivering minutes. Under PDPM the facility influences payment by describing the resident accurately, once, in the first eight days, and then by noticing when that description stops being true.
That is a harder discipline than it sounds, because it requires three things that rarely sit together: a chart that documents what is clinically real, an MDS coordinator who can find it, and a business office that can tell when the resulting HIPPS code disagrees with the chart. When any one of the three is missing, the building does not get an error message. It gets a slightly lower per diem, every day, silently, for as long as the pattern holds.
Source: FY2026 SNF PPS final rule (CMS-1827-F), 90 FR 37310, published August 4, 2025, effective October 1, 2025. federalregister.gov rule document and govinfo.gov full text. PDPM classification structure is published by CMS at cms.gov under the SNF PPS program.
Module 02 · the componentsSix components, six different failure modes.
Treating PDPM as one thing is the most common analytical mistake in skilled nursing finance. The five case-mix components fail independently, for different reasons, and respond to different fixes. A building can have excellent therapy documentation and an NTA score that is two points light because nobody codes comorbidities off the hospital discharge summary. The only way to see that is to decompose the per diem and look at each component against its own driver.
Physical therapy
Classified from a Section GG function score and a clinical category derived from the primary reason for the skilled stay. Sixteen groups. Carries the variable per diem decay from day 21 onward.
FAILURE: GG scored from one shift rather than usual performance across the observation windowOccupational therapy
Uses the same classification logic and the same function score as PT, which is why the two share a single HIPPS character. Sixteen groups, same decay curve.
FAILURE: the PT defect, doubled, because one GG error moves both components togetherSpeech-language pathology
Driven by an acute neurologic clinical category, a defined set of SLP comorbidities, cognitive impairment, the presence of a swallowing disorder, and a mechanically altered diet. Twelve groups, flat for the whole stay.
FAILURE: swallowing disorder and altered diet texture live in the chart but never reach Section KNursing
The widest component, twenty five groups, built from extensive services, clinical conditions, the depression indicator, restorative nursing programs, and the function score. Flat for the whole stay.
FAILURE: restorative nursing delivered daily but never documented to the frequency thresholdNon-therapy ancillary
A weighted point score across a defined comorbidity and extensive service list, collapsed into six groups. Paid at three times its value for days 1 through 3 to front-load admission drug and supply cost.
FAILURE: comorbidities present on the hospital record never coded onto the MDS in the lookbackNon-case-mix
Room, board, and administrative cost. No resident characteristic changes it, no assessment moves it, and no variable per diem applies. It is the floor under every covered day.
FAILURE: none available. This is the only component a coding error cannot understate.| Component | Groups | What sets the group | Variable per diem | Where it leaks |
|---|---|---|---|---|
| Physical therapy | 16 | Section GG function score and clinical category from the primary diagnosis | Decays from day 21 | Function scored from a single observation, not usual performance |
| Occupational therapy | 16 | Same function score and clinical category as PT, shared classification | Decays from day 21 | Any PT error is automatically an OT error |
| Speech-language pathology | 12 | Acute neurologic category, SLP comorbidities, cognition, swallowing, altered diet | Flat | Swallowing and diet texture not captured at admission |
| Nursing | 25 | Extensive services, clinical conditions, depression indicator, restorative nursing, function | Flat | Restorative programs and depression screening undocumented |
| Non-therapy ancillary | 6 | Weighted comorbidity and extensive service point score | 3.00 on days 1 to 3 | Hospital comorbidities never transcribed onto the MDS |
| Non-case-mix | n/a | Room, board and administrative cost, identical for every resident | Flat | Not exposed to coding error |
The HIPPS code on the claim is where the five classifications become one billable object. Five characters: the first carries the shared PT and OT group, the second the SLP group, the third the nursing group, the fourth the NTA group, and the fifth identifies which assessment produced the classification. That fifth character is the one most business offices never look at, and it is the one that tells you whether the claim is being priced off a 5-day assessment, an Interim Payment Assessment, or a default. A reconciliation that reads all five characters back against the assessment record catches most classification defects before the remittance does.
Module 03 · the clockTwo components are moving while you bill them.
Most per diem models in skilled nursing treat the rate as constant across the stay. It is not. PDPM applies a variable per diem adjustment to two of the six components, in opposite directions, on schedules that are published and entirely predictable. A facility that does not model the decay will over-forecast long stays and under-forecast short ones, and will misread a perfectly normal length-of-stay shift as a coding problem.
| Day of stay | PT and OT | SLP | Nursing | NTA | Non-case-mix |
|---|---|---|---|---|---|
| Days 1 to 3 | 1.00 | 1.00 | 1.00 | 3.00 | 1.00 |
| Days 4 to 20 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Days 21 to 27 | 0.98 | 1.00 | 1.00 | 1.00 | 1.00 |
| Days 28 to 34 | 0.96 | 1.00 | 1.00 | 1.00 | 1.00 |
| Days 35 to 41 | 0.94 | 1.00 | 1.00 | 1.00 | 1.00 |
| Days 42 to 48 | 0.92 | 1.00 | 1.00 | 1.00 | 1.00 |
| Days 49 to 55 | 0.90 | 1.00 | 1.00 | 1.00 | 1.00 |
| Days 56 to 62 | 0.88 | 1.00 | 1.00 | 1.00 | 1.00 |
| Days 63 to 69 | 0.86 | 1.00 | 1.00 | 1.00 | 1.00 |
| Days 70 to 76 | 0.84 | 1.00 | 1.00 | 1.00 | 1.00 |
| Days 77 to 83 | 0.82 | 1.00 | 1.00 | 1.00 | 1.00 |
| Days 84 to 90 | 0.80 | 1.00 | 1.00 | 1.00 | 1.00 |
| Days 91 to 97 | 0.78 | 1.00 | 1.00 | 1.00 | 1.00 |
| Days 98 to 100 | 0.76 | 1.00 | 1.00 | 1.00 | 1.00 |
The interrupted stay rule sits on top of this
The variable per diem counter does not automatically restart when a resident leaves. Under the interrupted stay policy, a resident who is discharged from the SNF and returns to the same facility within a defined interruption window resumes the stay where it left off: the same classification continues and the variable per diem day count picks up rather than resetting. If the return falls outside the window, or the resident returns to a different facility, a new stay begins with a new assessment and a fresh day count.
That distinction is worth real money in both directions, and it is one of the more common billing errors we see. A building that treats every readmission as a new stay files assessments it did not need and restarts a day count that should have continued, which overstates payment and creates audit exposure. A building that treats every return as an interruption misses genuine new stays and leaves the NTA triple and the full-value therapy days on the table. The control is a discharge and return log with the dates and the destination on it, reconciled against the assessment record weekly.
Module 04 · the assessmentThe MDS is not paperwork. It is the price file.
In every other part of the revenue cycle, the document that sets the price is guarded. Charge masters are governed, fee schedules are version controlled, coding is audited. In skilled nursing, the document that sets the price for up to one hundred consecutive days is completed by clinicians under time pressure, reviewed by one coordinator, and rarely audited against the chart it is supposed to summarize. That asymmetry is the single largest revenue integrity gap in the sector.
The 5-day PPS assessment carries an assessment reference date within the first eight days of the covered stay, and the classification it produces prices the whole stay unless an Interim Payment Assessment replaces it. There is no second chance built into the schedule. Whatever the assessment says about function, swallowing, diet, cognition, depression, extensive services, and comorbidities is what the resident is worth to the payment system, for every subsequent day, regardless of what the chart says.
Governing the Interim Payment Assessment
The IPA is the only mechanism PDPM provides for correcting a classification mid-stay when the resident's condition changes. Because it is optional, it needs a written trigger list or it will not happen consistently. The triggers that reliably matter are a new qualifying comorbidity or extensive service, initiation or discontinuation of isolation, a change in swallowing status or diet texture, a material change in Section GG function in either direction, a new intravenous medication course, and a change in the primary reason for the skilled stay. The assessment takes effect from its assessment reference date, which means a trigger noticed on day 22 and assessed on day 31 forfeits nine days.
The mirror obligation matters just as much. When a resident improves, the IPA is the honest instrument for reflecting that, and using it in only one direction is the pattern auditors look for. A building that files IPAs exclusively when they raise the rate has documented its own selection bias. The defensible posture is a trigger list applied symmetrically, with the reasoning recorded, so that the pattern across a year shows movement in both directions.
None of this works without a reverse audit. Take a sample of paid claims, pull the HIPPS code, decode all five characters, and go find the chart evidence for each classification decision. Where the evidence is thin, the exposure is a repayment. Where the evidence is strong but the code is low, the exposure is unrecovered revenue inside timely filing. Both directions belong in the same review, and running only the second one is how a revenue integrity program turns into an upcoding program.
Module 05 · the boundaryConsolidated billing decides who owns the bill.
During a covered Part A stay, Medicare pays the facility a single bundled per diem and the facility becomes financially responsible for nearly everything the resident receives. The exceptions are narrow and enumerated. Every service that falls inside the bundle and is billed to Medicare Part B by an outside supplier comes back rejected, and then arrives at the facility as an invoice, often months later, long past the point where it can be planned for.
The exclusions are set out at 42 CFR 411.15(p)(2). They cover physicians' professional services and the services of physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives, qualified psychologists, and certified registered nurse anesthetists. They cover dialysis and its related supplies and transport, erythropoietin for dialysis patients, hospice care furnished for the terminal condition, ambulance for the initial admission and the final discharge, certain chemotherapy items and their administration, radioisotope services, customized prosthetic devices, blood clotting factors for hemophilia, and rural health clinic and federally qualified health center services. CMS separately publishes an annual major categories file describing hospital outpatient services a SNF cannot furnish, including computed tomography, magnetic resonance imaging, cardiac catheterization, radiation therapy, and angiography.
Source: 42 CFR 411.15(p), services excluded from coverage, including the enumerated exceptions at paragraph (p)(2). ecfr.gov section text. CMS publishes the annual SNF consolidated billing major categories explanation and code files at cms.gov.
Two nuances trip up otherwise well-run buildings. The first is that therapy is never excluded. Not during a covered Part A stay, and not for a resident in the facility outside a Part A stay either, where Part B therapy must still be billed by the facility rather than by an outside therapist. The second is that the exclusion lists are annual files, not permanent facts. Codes move between the bundle and the exclusion list from one year to the next, which means a screening rule set that was correct in one federal fiscal year quietly becomes wrong in the next unless somebody owns refreshing it.
Module 06 · the routingBenefit exhaust is a lane change, not a stop.
Medicare Part A covers up to one hundred days of skilled care in a benefit period. When a resident exhausts those days, or drops below a skilled level of care while remaining in the building, the stay does not stop generating billable services. Therapy and certain ancillary services move to Part B. A facility that only runs a Part A billing workflow simply stops billing on the day the benefit runs out, and the resident days that follow become invisible.
The mechanics of the Part B lane are different enough to need their own workflow rather than an extension of the Part A one. Therapy under Part B is billed by discipline with its own documentation, plan of care and certification requirements, and its own claim form and code set. The people who assemble a Part A claim from a HIPPS code are not doing the same work. Where the two lanes share a workflow, the Part B lane tends to be starved, because the Part A claim is bigger and louder and always wins the queue.
There is a second, quieter version of the same failure. A resident who remains in the building but drops below a skilled level of care before day 100 also moves to Part B, and that transition has no calendar marker attached to it. It happens when a clinician makes a level-of-care judgement, and unless that judgement is wired into the billing system as an event, the days after it are simply lost. Our companion field work on accounts receivable workdown treats these as a distinct inventory class, because they age differently from denied claims and never surface in a denial report.
Module 07 · the divergenceMedicare Advantage runs a different game in the same building.
A skilled nursing facility with a meaningful Medicare Advantage mix is running two reimbursement systems side by side, in the same hallway, with the same clinicians. The fee-for-service resident is paid through PDPM and the revenue is won on assessment accuracy. The Medicare Advantage resident is paid through a contract and the revenue is won on authorization currency and concurrent review. Confusing the two is the most expensive category error in skilled nursing revenue cycle.
An MA plan is not required to pay a PDPM per diem. Some contracts do reference PDPM logic, but many pay level-of-care tiers, a flat negotiated per diem, or a case rate, and the plan manages length of stay through prior authorization and concurrent review rather than through an assessment. That has a direct operational consequence: an MDS that is perfectly coded does nothing for an MA day if the authorization lapsed on day nine. The two failure modes do not overlap, and a building that runs only one control will lose money on the other side.
| Dimension | Fee-for-service, PDPM | Medicare Advantage |
|---|---|---|
| Rate structure | Six components summed, wage index adjusted on the labor share | Negotiated: level-of-care tiers, flat per diem, or case rate |
| What sets the rate | The 5-day MDS assessment, replaced only by an IPA | The contract, plus the level of care the plan authorizes |
| Rate movement over the stay | PT and OT decay from day 21, NTA triples on days 1 to 3 | Whatever the contract says, commonly flat or tier stepped |
| Length of stay control | Coverage criteria and the 100 day benefit period limit | Prior authorization and concurrent review on the plan's clock |
| Assessment obligation | PPS assessment schedule drives payment | MDS still required for quality reporting, but not for payment |
| Dominant denial pattern | Assessment defects, HIPPS mismatch, default rate days | No authorization on file, auth expired mid-stay, missed review |
| Coverage criteria | Medicare coverage rules apply directly | Must follow traditional Medicare criteria, 88 FR 22120 |
| Where revenue is won | In the assessment window, in the first eight days | In the authorization queue, every day of the stay |
The regulatory floor under MA behaviour moved in 2023. The contract year 2024 Medicare Advantage final rule, published at 88 FR 22120 on April 12, 2023, requires MA organizations to comply with national and local coverage determinations and with general coverage and benefit conditions in traditional Medicare, and permits internal coverage criteria only where Medicare criteria are not fully established, with those criteria based on current evidence and made publicly accessible. That matters operationally rather than philosophically: it makes the stated basis of an MA denial an auditable object. When a plan denies continued skilled days on criteria that do not exist in traditional Medicare, the appeal has a specific and citable footing rather than a general appeal to reasonableness.
The practical architecture is one shared authorization tracker across all buildings and all plans, with an expiry countdown and a concurrent review date on every active MA stay, and a pre-bill gate that holds any claim whose service dates are not fully covered by a live authorization. That is the same discipline described in our prior authorization command center field guide, applied to a setting where the authorization governs bed days rather than procedures. The three-building SNF case study shows what the gate did to an authorization-related denial rate that started at fourteen percent.
Source: Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, 88 FR 22120, published April 12, 2023 (CMS-4201-F). federalregister.gov rule document.
The chart already justified the higher rate. The assessment is where the money was lost in translation, and nobody in the building thought of that form as a price file.
Composite of engagement findings across skilled nursing revenue integrity reviews
Module 08 · the taxonomyFive denial families cover most of the dollars.
Skilled nursing denials look chaotic on a remittance and resolve into a small number of families once they are coded consistently. The value of the taxonomy is not the categories. It is that each family maps to exactly one prevention gate, which turns a denial report into a work order instead of a lament.
| Denial family | Typical codes | Root cause | Prevention gate |
|---|---|---|---|
| Authorization, MA | CO-197, CO-15 | No authorization on file, authorization expired mid-stay, concurrent review date missed | Live auth gate holds the claim until the service dates are covered |
| Consolidated billing collision | CO-109 | Outside supplier billed Part B for a service inside the bundle during a covered Part A stay | Pre-bill bundle or exclusion screen at the point of order |
| Benefit exhaust and crossover | CO-96, PR-119 | Claims filed to Part A past the benefit limit because no Part B lane existed | Benefit day router with a projected exhaust date on every resident |
| Assessment defects | CO-16, N329 | Late or missing 5-day assessment, HIPPS mismatch against the assessment record, default rate days | Assessment calendar with a hard ARD deadline and a HIPPS tie-out |
| Eligibility and coordination | CO-27, PR-31 | Coverage terminated, Medicare secondary payer conflict, demographic mismatch | Eligibility check at admission and re-verified before every billing cycle |
| Prevention share | n/a | Every family above is preventable before the claim is created | Four gates and one eligibility check |
In the three-building engagement documented in our SNF PDPM cash recovery case study, authorization denials and consolidated billing collisions together accounted for fifty five percent of denied dollars in a ninety day baseline sample. Both are pre-bill patterns. Neither requires a clinical judgement to prevent. That distribution is typical rather than exceptional, which is why the sequence of a skilled nursing revenue integrity build almost always puts the authorization gate and the consolidated billing screen ahead of anything more sophisticated.
The 5-day assessment is coded to the chart, the IPA trigger list is applied symmetrically, and the HIPPS code ties out against the assessment record before the claim drops.
GATE 01Every resident carries a benefit day count and a projected exhaust date. The Part B lane opens automatically on that date or on a documented level-of-care change.
GATE 02Bundle or exclusion is decided at the point of order against the current federal fiscal year file, not after a supplier invoice arrives four months later.
GATE 03No Medicare Advantage claim leaves the building unless a live authorization covers every service date on it, with the concurrent review clock visible.
GATE 04Module 09 · the scorecardNine numbers that tell you whether the stack is telling the truth.
A skilled nursing revenue integrity program needs a scorecard that a director of nursing, an MDS coordinator and a chief financial officer can all read from the same page. These nine measures do that. None of them require a data warehouse. All of them are computable from the assessment record, the census, and the remittance file.
Every reported per diem breaks into its six components. If you can only report the total, this measure is zero regardless of how good the total looks.
Share of covered Part A stays with a 5-day assessment reference date inside the required window. Anything short of complete produces default rate days.
Days paid at the default rate because an assessment was late, missing, or unaccepted. This is the only KPI on the list whose target is literally zero.
Share of claims whose five HIPPS characters match the classification in the assessment record. Mismatches are billing defects, not coding opinions.
Difference between the NTA point score on the MDS and the score supportable from the hospital record and the chart on a sampled audit.
Interim Payment Assessments filed in both directions over a rolling year. A one-directional pattern is the shape auditors look for first.
Resident days after Part A exhaust or a level-of-care drop that have generated no Part B claim. Count it this morning before you argue about it.
Share of Medicare Advantage bed days fully covered by a live authorization at the moment of billing. Partial coverage is a denial waiting for a claim.
Dollar value of supplier invoices received for bundled services that were never screened pre-bill. Trending this to zero is the whole point of gate three.
Two of these deserve a note. Default rate days are the only measure on the list with a target of zero and no acceptable variance, because a default rate day is a self-inflicted wound with no clinical justification available. And IPA symmetry is the measure that keeps a revenue integrity program honest, because a program that only ever finds reasons to raise the rate is not a revenue integrity program. It is an upcoding program with better documentation, and it will eventually be read that way by someone with subpoena power.
Module 10 · the ruleWhat FY2026 actually changed, and what it did not.
Rate year noise absorbs a disproportionate amount of executive attention in skilled nursing. It is worth separating the part of the annual rule that changes the arithmetic from the part that changes the operating model, because in most years those are very different in size.
The FY2026 SNF PPS final rule, CMS-1827-F, was published in the Federal Register on August 4, 2025 at 90 FR 37310 and took effect October 1, 2025. CMS finalized a net update of 3.2 percent, built from a 3.3 percent SNF market basket increase, a positive 0.6 percentage point market basket forecast error adjustment, and a negative 0.7 percentage point productivity adjustment.
The FY2026 labor-related share is 71.9 percent, which is the portion of the rate exposed to the area wage index. The permanent policy limiting any year over year decrease in a provider's wage index to 5 percent continues to apply, so a facility in a falling wage index area has a known floor on the annual damage rather than an open-ended one.
The PDPM parity adjustment that dominated skilled nursing budget conversations for two years is finished. CMS recalibrated the parity adjustment factor by 4.6 percent in total and phased it over two fiscal years, lowering the factor from 46 percent to 42 percent in FY2023 and from 42 percent to 38 percent in FY2024, which completed the recalibration. FY2026 carries no further parity phase-in. Any budget model still carrying a parity assumption forward is modeling a change that is already in the base.
Source: FY2026 SNF PPS final rule (CMS-1827-F), 90 FR 37310, published August 4, 2025, effective October 1, 2025, govinfo.gov full text. Parity adjustment phase-in described in the FY2024 SNF PPS final rule at 88 FR 53200. CMS publishes the corresponding fact sheets and rate tables at cms.gov.
Set against everything in the preceding nine modules, a 3.2 percent update is a small number. A building carrying a case-mix per diem that is understated by even a few percent because of systematic function-score conservatism, or paying twice for bundled services that were never screened, or leaving post-exhaust days unbilled, is losing more than the annual update is giving. That is not an argument for ignoring the rule. It is an argument for spending proportionally more attention on the part of the rate the facility actually controls.
Module 11 · FAQSix questions SNF operators ask us.
What are the five PDPM case-mix components?
Physical therapy, occupational therapy, speech-language pathology, nursing, and non-therapy ancillary. Each is classified into its own case-mix group and priced separately, then added to a sixth non-case-mix component that covers room, board, and administrative cost. PT has 16 groups, OT has 16, SLP has 12, nursing has 25, and NTA has 6. The five case-mix groups are what the five-character HIPPS code on the claim encodes, with PT and OT sharing the first character and the fifth character identifying the assessment used.
How does the variable per diem schedule work under PDPM?
Two components change value as the stay ages. PT and OT are paid at an adjustment factor of 1.00 for days 1 through 20, then the factor steps down by 0.02 every seven days, reaching 0.76 for days 98 through 100. NTA runs the opposite way: an adjustment factor of 3.00 applies to days 1 through 3 to front-load the cost of admission medications and supplies, then drops to 1.00 for days 4 through 100. SLP, nursing, and the non-case-mix component carry no variable per diem adjustment and stay flat for the whole stay.
Why is the 5-day MDS assessment a revenue integrity control?
The 5-day PPS assessment sets the HIPPS code that prices every covered Part A day of the stay unless an Interim Payment Assessment replaces it. One assessment window, with an assessment reference date in the first eight days, determines up to 100 days of payment across five components at once. An understated Section GG function score, a missing swallowing or mechanically altered diet item, an uncoded depression screen, or a comorbidity that never made it out of the chart is not a one-day error. It repeats every day until discharge.
When should a SNF file an Interim Payment Assessment?
When the resident's clinical picture changes enough that the classification driven by the 5-day assessment no longer describes them. The IPA is optional under PDPM, which is exactly why it gets skipped. It should be governed by written triggers: a new qualifying comorbidity or extensive service, a change in swallowing status or diet texture, a material change in Section GG function, initiation of isolation, or a new IV medication course. The IPA takes effect on its assessment reference date, so a late IPA forfeits the days between the clinical change and the assessment.
What is excluded from SNF consolidated billing?
During a covered Part A stay the SNF bundle covers nearly everything, and the exceptions are enumerated at 42 CFR 411.15(p)(2): physicians' professional services and the services of physician assistants, nurse practitioners, clinical nurse specialists, nurse-midwives, qualified psychologists, and certified registered nurse anesthetists, plus dialysis and related supplies and transport, erythropoietin for dialysis patients, hospice care for the terminal condition, ambulance for the initial admission and final discharge, certain chemotherapy items and their administration, radioisotope services, customized prosthetic devices, blood clotting factors, and rural health clinic and federally qualified health center services. CMS also publishes an annual major categories file covering hospital outpatient services that a SNF cannot furnish, including CT, MRI, cardiac catheterization, radiation therapy, and angiography. Therapy is never on the excluded list.
How does Medicare Advantage diverge from fee-for-service PDPM?
An MA plan is not required to pay a PDPM per diem. Most pay a negotiated rate structure, often level-of-care tiers or a flat per diem, and they manage the stay with prior authorization and concurrent review rather than an assessment. That produces two different operating models in the same building: FFS days are won on MDS accuracy, MA days are won on authorization currency. Since the contract year 2024 Medicare Advantage final rule at 88 FR 22120, MA plans must follow traditional Medicare coverage criteria and may use internal criteria only where Medicare criteria are not fully established, which makes the denial letter's stated basis an auditable object rather than a matter of plan discretion.
Can you name your per diem component by component?
Send ninety days of remittance data with CARC and RARC codes, your MDS 5-day extract with HIPPS codes, your Medicare Part A census with benefit exhaust dates, and your Medicare Advantage authorization log. A senior partner returns a written audit covering PDPM component gaps, consolidated billing exposure, unbilled Part B days, authorization risk, recoverable dollars, and a ninety day fix plan.