Top Nursing Home Missed Reimbursement Opportunities

Top Nursing Home Missed Reimbursement Opportunities

Practical Strategies to Capture What You’ve Rightfully Earned

In today’s long-term care environment, nursing homes are under more pressure than ever to deliver high-quality care while navigating increasingly complex reimbursement systems. Between PDPM, Medicaid Case Mix, managed care rules, and ever-evolving CMS guidance, it’s no surprise that many facilities unintentionally leave significant revenue on the table. Let’s review the top patterns of missed reimbursement opportunities we’ve seen emerge again and again in skilled nursing facilities—and more importantly, how to prevent them:

1. Missing or Untimely MDS Assessments

Missing assessments or late assessment reference dates (ARDs), failure to submit assessments in a timely manner, or errors in completion of the correct assessment type can result in lost days of coverage or payment penalties.

Action Tip: Implement a reliable MDS calendar with internal alerts. Hold a weekly IDT meeting focused on upcoming ARDs and ensure timely completion and transmission.

2. Inaccurate Functional Status Coding

Section GG drives PDPM functional scoring—and when it’s inaccurately assessed or inconsistently documented, it can significantly lower PDPM reimbursement. Too often, team members score based without a full understanding of the task or the coding definitions, resulting in an incorrect assessment of the resident’s actual usual performance during the lookback period.

Action Tip: When reviewing the interdisciplinary documentation during the three-day assessment, use a standardized approach to determine the “usual” performance. Cross-check scoring during the Medicare meeting to ensure consistency before final coding. Be sure to include an IDT note for the GG lookback period that reflects how the team determined the resident’s usual performance—this helps support accuracy and ultimately is a significant factor in withstanding audit scrutiny

3. Missed Speech-Language Pathology (SLP) Opportunities

The SLP component is often understated due to a lack of recognition for cognitive, speech related comorbidities, and swallowing issues, yet it offers one of the highest reimbursement opportunities under PDPM.

Action Tip: Train staff to flag cognitive changes, swallowing difficulties, and behaviors, such as oral pocketing of food or refusal to eat. Also, don’t overlook the importance of timely completion of the BIMS interview, and Section K data.

4. Uncaptured NTA Points

Non-Therapy Ancillary points are often missed due to documentation gaps or delays in diagnosis coding. Capturing these points can have a significant impact on payment in the first 3 days of the Medicare stay.

Action Tip: Review hospital records immediately upon admission. Identify NTA-qualifying conditions (e.g., wounds, IV meds, comorbidities) and ensure timely documentation and diagnosis entry. Implement a physician query process to obtain MD support for improved specificity in coding

5. Failure to identify Opportunities to complete Interim Payment Assessments (IPAs)

Identification of clinical changes that impact resident acuity and have the potential to increase the cost of care provided is critical to accurate and appropriate reimbursement. IPAs, when completed, can have a significant financial impact which is effective on the ARD. Many facilities lack a process of timely identification of changes that support the appropriate completion of an IPA to be reimbursed for the extra care required in these instances.

Action Tip: Establish IPA triggers for your team—functional declines, new pressure injuries, or significant treatment changes. Use a quick referral checklist to initiate IPA reviews.

6. Lack of a Process of ADR request and denials management

With the rise in Medicare Advantage and Managed Medicaid, denial management is more critical than ever. Many facilities don’t appeal when they should—or fail to document medical necessity thoroughly.

Action Tip: Implement and effect pre-billing Triple Check Process. Next, develop a structured medical review response and appeals process with templated letters, physician narratives, and a tracking system. Assign a team lead to monitor and escalate cases.

Final Thoughts

Reimbursement in long-term care is more than a billing task—it’s a clinical and operational strategy. By tightening your documentation processes, aligning team communication, and conducting regular audits, you can significantly increase revenue.

Next Steps:

• • Access Proactive’s PDPM policies and procedures and toolkits
  • Contact Proactive to schedule a Reimbursement Opportunity Audit and start capturing your earned dollars today
  • Register for the Capturing Accurate Reimbursement webinar series which begins July 9, 2025

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