SNF Revenue Infrastructure
Medbilling RCM provides specialized nursing home and skilled nursing facility billing services covering PDPM classification, Medicare Part A and Part B billing, MDS accuracy review, Medicaid state-specific billing, consolidated billing compliance, and Triple Check process support — ensuring accurate claims and maximum reimbursements for SNFs and long-term care facilities.
PDPM Payment Components
Under the Patient-Driven Payment Model, your Medicare Part A per-diem rate is the sum of five independently calculated case-mix components — each derived from MDS assessment data. Errors in any component affect the daily rate for the entire stay.
PT case-mix group derived from MDS Section GG functional scores and primary diagnosis
OT component calculated from ADL function scores — often miscoded reducing daily rate
SLP classification driven by cognitive status, swallowing disorders, and respiratory failure
Nursing component — highest weight in PDPM — derived from extensive conditions list in MDS
NTA captures high-cost medications, IV therapy, tracheostomy, ventilator, and complex medical needs
SNF Billing Challenges
SNF billing has a 15.1% improper payment rate (CMS 2022 data) — among the highest in healthcare. Most errors originate from MDS inaccuracies, PDPM miscalculation, consolidated billing violations, and Part A/B coverage misclassification.
MDS accuracy is the most consequential billing variable in SNF billing. An incorrect MDS item can reduce all five PDPM payment components for the entire stay. We review MDS data, verify ICD-10 coding, and conduct pre-submission accuracy checks before every RAI submission — preventing systematic daily rate reductions from documentation errors.
Medicare Part A covers the SNF stay for qualified beneficiaries; Medicare Part B covers outpatient skilled services for residents not in a covered Part A stay. Misclassifying services between tracks generates denials and compliance risk. We manage both billing tracks simultaneously, ensuring correct classification at every point in the resident's care continuum.
Under consolidated billing, most services provided during a Part A SNF stay must be billed by the SNF — not by outside providers. Violations occur when therapy companies, labs, or DME suppliers bill Medicare directly for bundled services. We manage consolidated billing compliance, identify separately billable Part B services, and prevent billing conflicts that trigger OIG audit risk.
The Triple Check process verifies MDS data, therapy documentation, and billing data are consistent before submitting Medicare Part A claims. It prevents PDPM miscalculations from MDS inaccuracies and inconsistencies between therapy minutes and billing. We implement Triple Check protocols on every Part A claim cycle, preventing the most costly SNF billing errors before claims are submitted.
Medicaid nursing home billing varies significantly by state — each state sets its own rate methodology, eligibility criteria, case-mix systems, and billing cycles. We maintain current knowledge of state-specific requirements and manage coverage transitions for residents moving from Medicare Part A to Medicaid, preventing revenue gaps during payer changes.
Medicare Part A claims have a 12-month timely filing deadline from the date of service. Missing this deadline results in permanent revenue loss with no appeal remedy. We manage SNF AR on a structured weekly cycle with documented action plans for every account over 60 days — preventing the quiet revenue erosion from aging uncollected SNF claims.
Revenue Control Framework
End-to-end SNF billing infrastructure from admission PDPM classification through Medicaid coverage transition — built for the regulatory complexity of skilled nursing facility reimbursement.
Review ICD-10 primary diagnosis and MDS data at admission to optimize PDPM classification across all five case-mix components before the first Part A claim
Pre-submission MDS review — verify Section GG scores, cognitive assessments, and condition documentation drive accurate PDPM component rates
Three-point verification: therapy documentation vs. billing, MDS coding vs. clinical records, and billing data reconciliation before every Part A submission
Identify all separately billable Part B services, manage outside provider billing conflicts, and ensure consolidated billing compliance throughout the stay
Manage coverage transitions — Part A exhaustion, swing beds, Medicaid crossover — ensuring no billing gaps during payer changes
Weekly AR aging review, documented follow-up plans, and proactive monitoring of all claims approaching the 12-month Part A timely filing deadline
Operational Transformation
Why Medbilling RCM
Our SNF billing team understands PDPM case-mix components, MDS accuracy requirements, Triple Check protocols, consolidated billing rules, and the state-specific Medicaid billing complexity that determines financial performance for long-term care facilities.
All five PDPM components reviewed for every resident at admission and reassessment — ensuring maximum per-diem rates throughout the stay.
Pre-submission MDS review catches coding errors that systematically reduce payment components for the full duration of the resident's Medicare stay.
Three-point verification — therapy, MDS, and billing — on every Part A claim cycle prevents the most costly SNF billing errors before submission.
Simultaneous management of both billing tracks with correct service classification at every point in the care continuum.
Full consolidated billing management — identifying separately billable Part B services and preventing outside-provider billing conflicts.
Current Medicaid rate methodology, billing cycle, and eligibility rules for every state where your residents receive coverage.
Weekly AR review with documented action plans — zero Medicare Part A timely filing deadline misses. 12-month clock tracked for every claim.
Per-resident revenue tracking, PDPM component performance reports, payer mix analysis, and census-to-revenue reconciliation.
Common Questions
Direct answers about PDPM, MDS accuracy, consolidated billing, Medicare Part A/B, Medicaid billing, and the Triple Check process. View all specialties we serve.
Under the Patient-Driven Payment Model (PDPM), Medicare Part A per-diem rates are determined by clinical complexity across five case-mix components: Physical Therapy, Occupational Therapy, Speech-Language Pathology, Nursing, and Non-Therapy Ancillaries. Each component rate is derived from MDS assessment data. MDS accuracy is the most consequential billing variable — an incorrect MDS item can systematically reduce all five payment components throughout the patient's stay. We review MDS data and ICD-10 coding before every RAI submission.
Under consolidated billing, Medicare requires that most services provided to beneficiaries during a covered Part A SNF stay be billed by the SNF in a single consolidated claim — not by the individual therapy, ancillary, or professional service provider. This means most outside providers (therapy companies, labs, DME suppliers) must look to the SNF for payment. Services that CAN be separately billed to Part B include certain physician services, specific lab tests, and ambulance transportation. We manage consolidated billing compliance and identify which services are separately billable from Part B.
Medicare Part A covers the first 100 days of a qualifying SNF stay (100% for days 1–20, coinsurance for days 21–100) following a three-day inpatient hospital stay. Medicare Part B covers outpatient skilled services for residents not in a covered Part A stay. The two programs have different claim formats, documentation requirements, and fee schedule rates. We manage both billing tracks simultaneously, ensuring correct classification of services under Part A or Part B at every point in the resident's stay.
Medicaid nursing home billing varies significantly by state — each state sets its own rate methodology, eligibility criteria, and billing requirements. We maintain current knowledge of state-specific Medicaid rate structures, billing cycles, and documentation requirements. For residents transitioning from Medicare Part A to Medicaid coverage, we manage the billing crossover, ensure correct payer sequencing, and prevent revenue gaps during coverage transitions.
The Triple Check process is a pre-billing quality review that verifies MDS data, therapy documentation, and billing data are all consistent and accurate before submitting Medicare Part A claims. It involves three separate review points: therapy verification against clinical documentation, MDS coding accuracy review, and billing data reconciliation. The Triple Check prevents the most common and costly SNF billing errors — PDPM miscalculations from MDS inaccuracies and inconsistencies between therapy minutes and billing data. We implement Triple Check protocols on every Medicare Part A claim cycle.
Revenue Assessment
Schedule a free SNF billing assessment and discover how PDPM optimization, MDS accuracy review, and Triple Check implementation can recover missed revenue and prevent improper payment exposure.
