Skilled Nursing Facility Billing Company | Expert SNF Revenue Cycle Management

Skilled Nursing Facilities occupy a unique and challenging position within the healthcare continuum, serving as both homes and healthcare providers for millions of elderly and disabled Americans. These facilities deliver complex medical care, rehabilitative therapy, and supportive services to residents with diverse needs, all while navigating one of the most complicated reimbursement systems in American healthcare. The financial success of any SNF depends on selecting the right skilled nursing facility billing company as a strategic partner.

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The transition from the Resource Utilization Group system to the Patient-Driven Payment Model in October 2019 fundamentally transformed SNF reimbursement. Payment no longer correlates directly with therapy minutes provided but instead depends on resident clinical characteristics captured through Minimum Data Set assessments. This shift placed unprecedented importance on accurate clinical documentation and seamless integration between clinical and financial operations.

A dedicated SNF billing company brings specialized expertise in this complex environment. They understand skilled nursing medical billing services requirements, manage PDPM billing specialist’s coordination, and ensure compliance with SNF consolidated billing management rules. By partnering with the right nursing home billing company, facility administrators focus on resident care while maximizing revenue and maintaining financial sustainability.

Understanding the Skilled Nursing Facility Landscape

Skilled Nursing Facilities provide twenty-four hour nursing care, rehabilitative therapy, and medical oversight to residents requiring services beyond what assisted living or home care can provide. These facilities serve diverse populations including short-term post-acute patients recovering from hospitalizations and long-term residents requiring chronic care management.

The financial model for SNFs reflects this diversity of services and residents. Facilities must manage Medicare Part A coverage for skilled stays, Medicare Part B for outpatient therapy, Medicaid for long-term custodial care, managed care contracts, private pay residents, and long-term care insurance policies. Each payer source carries distinct requirements, payment rates, and administrative processes.

Post-acute care billing company expertise proves essential for navigating this complexity. Short-term Medicare residents generate different revenue streams than long-term Medicaid residents, and facilities must optimize both while maintaining compliance with all regulatory requirements. The right billing partner understands these distinctions and manages each accordingly.

The Patient-Driven Payment Model Explained

The Patient-Driven Payment Model represents the most significant change in SNF reimbursement in decades. Unlike the previous RUG system that based payment primarily on therapy minutes provided, PDPM focuses on resident clinical characteristics to determine per diem payment rates.

Under PDPM, each resident receives classification across five distinct case-mix components: physical therapy, occupational therapy, speech-language pathology, nursing, and non-therapy ancillary. Each component generates its own per diem rate based on assessment data captured in the Minimum Data Set. PDPM billing specialists understand how each component interacts and how to optimize classification for appropriate reimbursement.

This model eliminates financial incentives to provide therapy based on payment considerations rather than clinical need. However, it places unprecedented importance on accurate MDS assessments, as classification at admission and upon significant change determines reimbursement for the entire stay. Maximize SNF reimbursement rates through accurate, timely MDS completion.

MDS Assessment and Billing Coordination

The Minimum Data Set serves as the foundation of SNF reimbursement under PDPM. This comprehensive clinical assessment captures resident health status, functional capabilities, cognitive condition, and service needs, generating data used for care planning, quality measurement, and payment determination.

MDS assessment and billing coordination requires seamless collaboration between clinical staff completing assessments and billing professionals submitting claims. The five-day assessment establishes initial PDPM classification, the fourteen-day assessment may adjust classification for stabilized residents, and significant change in status assessments capture major clinical developments.

MDS lock date monitoring proves critical for reimbursement accuracy. Assessments must be completed within prescribed windows and submitted to CMS through the Internet Quality Improvement and Evaluation System before lock dates expire. Late or missing assessments result in payment delays, reduced rates, and potential denials that specialized billing partners help prevent.

HIPPS Code Calculation Accuracy

Health Insurance Prospective Payment System codes translate MDS assessment data into the case-mix classifications that determine Medicare payment rates. HIPPS code calculation services combine information from all five PDPM components into codes that appear on each claim.

HIPPS codes consist of five or six characters representing resident classification for each payment component. Physical and occupational therapy components combine into a single character, while speech-language pathology, nursing, and non-therapy ancillary each contribute separate characters. Accurate code assignment depends entirely on correct MDS completion and coding.

SNF claim submission management includes verifying that HIPPS codes match current assessment data and that claims spanning multiple classification periods use appropriate codes for each service date. Errors in HIPPS code assignment lead to payment adjustments, denials, and audit exposure that specialized billing partners prevent.

Medicare Part A SNF Billing Company Expertise

Medicare Part A covers Skilled Nursing Facility care for eligible beneficiaries requiring daily skilled services following a qualifying hospital stay. Medicare Part A SNF billing company expertise ensures that facilities capture appropriate reimbursement for these covered stays.

Part A coverage requires a three-day prior inpatient hospitalization, admission within thirty days of hospital discharge, and ongoing need for daily skilled services. Coverage extends for up to one hundred days per benefit period, with full coverage for the first twenty days and coinsurance required for days twenty-one through one hundred.

Medicare timely filing compliance demands that claims be submitted within twelve months of service date. Facilities must track benefit period usage, monitor skilled need continuously, and discharge residents appropriately when skilled services no longer required. Specialized billing partners manage these requirements while maximizing covered day reimbursement.

Medicare Part B Therapy Billing for SNFs

Residents not in a Medicare Part A covered stay may still receive skilled services under Medicare Part B. Medicare Part B therapy billing for SNFs covers physical therapy, occupational therapy, and speech-language pathology services provided to residents regardless of Part A benefit status.

Part B therapy services require physician orders, skilled therapy need, and ongoing documentation of treatment and progress. Services are billed using therapy-specific CPT codes with appropriate modifiers indicating therapy discipline and service type. Therapy minute documentation review ensures that documentation supports medical necessity and justifies continued services.

The annual therapy threshold and targeted medical review requirements add complexity to Part B therapy billing. Services exceeding certain thresholds may trigger additional documentation review, requiring facilities to maintain robust clinical records supporting all therapy provided. Specialized billing partners monitor threshold status and prepare for potential review.

SNF Consolidated Billing Management

Skilled Nursing Facilities operate under consolidated billing requirements that designate the facility as the sole billing source for most services provided to residents during covered stays. SNF consolidated billing management ensures that facilities understand which services fall within the bundled payment and which may be billed separately.

Consolidated billing identifies specific service categories that fall within the SNF prospective payment, including most routine services, therapy, and certain diagnostic tests. Services outside the consolidated billing umbrella, such as physician professional services and certain high-cost items, may be billed separately by outside providers.

SNF consolidated billing rules management includes educating vendors about billing requirements, monitoring claims from outside providers to prevent inappropriate billing, and appealing denials when services are incorrectly excluded from consolidated billing. Effective management prevents payment disruptions and ensures facilities receive appropriate reimbursement.

Medicaid Nursing Facility Billing Services

Medicaid serves as the primary payer for long-term custodial care, covering residents who have exhausted personal resources and meet clinical eligibility criteria. Medicaid nursing facility billing services must navigate varying state requirements, payment methodologies, and administrative processes.

Its eligibility involves both clinical and financial criteria. Residents must require nursing facility level of care and meet income and asset limits established by state programs. Medicaid eligibility verification requires ongoing monitoring as resident circumstances change and as states periodically redetermine eligibility.

Many residents qualify as dual eligible, covered by both Medicare and Medicaid. For these residents, Medicare covers skilled services while Medicaid covers custodial care and cost-sharing responsibilities. Coordinating benefits for dual eligible residents requires careful attention to payment ordering and crossover claim processing.

Medicare Advantage SNF Billing

As Medicare beneficiaries increasingly enroll in private Medicare Advantage plans, SNFs must navigate varying coverage policies, prior authorization requirements, and payment methodologies. Medicare Advantage SNF billing requires understanding each plan’s specific requirements and maintaining current contract information.

Medicare Advantage plans may have different coverage criteria than traditional Medicare, including prior authorization requirements for SNF admissions and continued stay reviews. Facilities must verify coverage before admission, obtain necessary authorizations, and submit claims according to plan specifications.

Managed care SNF contracting involves negotiating payment rates, understanding plan requirements, and maintaining current contracts with multiple plans. Facilities serving diverse resident populations may contract with dozens of plans, each with unique requirements and payment rates.

VA Nursing Home Billing Services

The Department of Veterans Affairs operates Community Living Centers and contracts with community nursing homes to serve eligible veterans. VA nursing home billing services involve specific contracts, payment rates, and reporting requirements that differ from other payers.

VA contract nursing home programs require facilities to meet VA standards, accept VA-determined payment rates, and submit claims through VA systems. Facilities must verify veteran eligibility, obtain necessary authorizations, and coordinate with VA case managers on care planning and discharge.

For veterans eligible for both VA benefits and Medicare or Medicaid, coordination of benefits determines payment order and facility reimbursement. Understanding these relationships ensures that facilities receive appropriate payment from all available sources.

SNF Denial Management Experts

Denials in skilled nursing facilities arise from various sources, including coverage determinations, coding errors, documentation deficiencies, and billing mistakes. SNF denial management experts systematically identify denial causes and pursue appropriate payment through appeals and corrected claims.

Common denial reasons include insufficient documentation of skilled need, missed MDS assessment deadlines, incorrect HIPPS code assignment, failure to meet coverage criteria, and timely filing expirations. Each denial type requires specific appeal strategies and supporting documentation.

Reduce nursing home claim denials through proactive denial prevention, including regular internal audits, staff training, and system edits that catch errors before claim submission. When denials occur, persistent follow-up and well-documented appeals maximize recovery.

SNF Accounts Receivable Management

Effective accounts receivable management ensures that facilities collect payments promptly and minimize aging receivables. SNF accounts receivable management includes monitoring payment patterns, following up on unpaid claims, and escalating collection efforts as needed.

Aging reports track receivables by payer and age, identifying accounts requiring attention. Regular analysis of aging patterns reveals payer-specific issues, systemic problems, and opportunities for improvement. Nursing home payment posting ensures that payments are applied correctly and that discrepancies are identified promptly.

Cash flow forecasting depends on accurate receivable information and understanding of payment patterns. Facilities with strong receivable management maintain predictable cash flow, supporting operational stability and strategic planning.

SNF Regulatory Compliance Services

Skilled Nursing Facilities operate under extensive federal and state regulations governing every aspect of operations. SNF regulatory compliance services ensure that billing practices align with requirements and that facilities maintain survey readiness.

SNF conditions of participation compliance addresses Medicare requirements for participation, including resident rights, quality of care, and administrative standards. Billing compliance intersects with clinical requirements through MDS accuracy, documentation standards, and coverage determinations.

Nursing home survey readiness requires ongoing attention to regulatory requirements and prompt correction of identified deficiencies. Billing practices may come under survey scrutiny, particularly regarding medical necessity documentation and services billed.

Medicare Cost Report Preparation for SNFs

Medicare cost reports reconcile interim payments with actual costs and determine final reimbursement for certain services. Medicare cost report preparation for SNFs requires specialized expertise in cost reporting principles and SNF-specific requirements.

Cost reports capture detailed information about facility costs, utilization, and patient characteristics. Costs must be allocated appropriately between Medicare, Medicaid, and other payers based on allowable cost principles and utilization statistics.

Accurate cost reporting ensures that facilities receive appropriate reimbursement and maintain compliance with Medicare requirements. Cost report data also supports rate setting, budget planning, and financial analysis.

Technology Integration for SNF Billing

Effective SNF billing depends on technology designed for the unique requirements of skilled nursing facilities. SNF billing software integration ensures that clinical documentation flows seamlessly to billing systems, supporting accurate coding and claim submission.

MDS software connectivity between assessment systems and billing platforms reduces duplicate data entry and improves accuracy. When MDS assessments automatically generate HIPPS codes and feed claim information, facilities reduce errors and accelerate payment cycles.

Nursing home EHR billing integration connects clinical documentation with revenue cycle management, supporting medical necessity documentation and coding accuracy. Integrated systems provide comprehensive visibility into facility operations and financial performance.

Transitioning to Outsourced SNF Billing

Many skilled nursing facilities that have managed billing internally consider transitioning to outsourced partners to improve results and reduce administrative burden. Transitioning from in-house to outsourced SNF billing requires careful planning and execution.

The transition process begins with comprehensive assessment of current operations, including billing metrics, staff capabilities, and technology systems. A detailed transition plan addresses data migration, staff training, and communication with payers and vendors.

Skilled nursing facility billing company reviews from other facilities provide insight into partner capabilities and results. Speaking with references and reviewing performance metrics helps facilities select the right partner for their specific needs.

Cost Analysis: Outsourcing SNF Billing

Maintaining SNF billing capabilities internally requires significant investment in personnel, technology, and training. Billing staff must understand PDPM, MDS assessment coordination, consolidated billing, and multiple payer requirements. Technology must support assessment submission, claim generation, and comprehensive reporting.

Outsourcing to a specialized skilled nursing facility billing company eliminates these costs while improving results. The nursing home billing company cost and pricing typically ranges from four to seven percent of collected revenue, comparable to industry rates but with the advantage of specialized SNF expertise.

Beyond direct cost savings, outsourcing delivers value through improved collection rates, reduced administrative burden, and enhanced compliance. Specialized billing partners stay current with regulatory changes, payer policies, and technology advancements that individual facilities cannot track effectively.

Maximizing SNF Financial Performance

Optimizing financial performance for skilled nursing facilities requires systematic attention to every element of the revenue cycle. From pre-admission verification through final payment posting, each step affects ultimate financial results.

Learn advanced revenue cycle methodologies through Healthcare Financial Management Association.

Maximize SNF reimbursement rates through comprehensive revenue cycle management addressing all available funding sources. Medicare Part A coverage for skilled stays forms the foundation, supplemented by Medicare Part B therapy, Medicaid payments, managed care contracts, and private resources.

SNF financial performance improvement requires ongoing monitoring of key metrics, including clean claim rates, denial percentages, days in accounts receivable, and net collection rates. Regular analysis identifies opportunities for improvement and measures progress over time.

Frequently Asked Questions

What should I look for in a skilled nursing facility billing company?

When selecting a skilled nursing facility billing company, look for demonstrated expertise in PDPM billing specialists coordination, MDS assessment and billing coordination, and SNF consolidated billing management. The company should have experience with your payer mix, technology that integrates with your systems, and a track record of improving client financial performance. Skilled nursing facility billing company reviews and references provide valuable insight into partner capabilities.

How does PDPM affect SNF billing and reimbursement?

PDPM (Patient-Driven Payment Model) billing bases payment on resident clinical characteristics rather than therapy minutes provided. Five case-mix components determine per diem rates: physical therapy, occupational therapy, speech-language pathology, nursing, and non-therapy ancillary. HIPPS code calculation services translate MDS assessment data into payment codes, making accurate assessment completion absolutely critical to appropriate reimbursement.

What is the difference between Medicare Part A and Part B in SNFs?

Part A vs Part B skilled services determines coverage based on resident benefit status. Medicare Part A SNF billing company expertise covers skilled stays following qualifying hospital admissions, with payment under PDPM. Medicare Part B therapy billing for SNFs covers services for residents not in a Part A benefit period, billed separately using therapy codes. Facilities must track benefit periods to bill services appropriately.

What is SNF consolidated billing and why does it matter?

SNF consolidated billing designates the facility as the sole billing source. For most services provided to residents during Medicare covered stays. The facility receives a bundled payment covering included services, and outside providers cannot bill separately. SNF consolidated billing rules management ensures that vendors bill appropriately and that facilities receive proper reimbursement for covered services.

How can outsourcing SNF billing improve my facility’s financial performance?

Outsourcing to a specialized skilled nursing facility billing company improves financial performance through higher collection rates. Reduced denials, and enhanced compliance. SNF denial management experts systematically address claim issues, while SNF accounts receivable management accelerates payment cycles. Transitioning from in-house to outsourced SNF billing eliminates personnel and technology. Costs while accessing specialized expertise that individual facilities cannot maintain internally.

Final Considerations

Skilled Nursing Facilities serve as essential healthcare providers for millions of Americans. Delivering complex medical care and supportive services to residents with diverse needs. The complex reimbursement systems that sustain these facilities—PDPM, consolidated billing. Medicaid methodologies, and managed care contracts—require specialized revenue cycle management expertise that general billing companies cannot provide.

Partnering with a dedicated skilled nursing facility billing company strengthens the financial foundation of your facility. From PDPM billing specialists coordination to MDS assessment and billing coordination. Expert billing partners handle the complexity so you can focus on resident care. They navigate SNF consolidated billing management. Manage Medicare Part A SNF billing company requirements, and ensure that every eligible service generates maximum reimbursement.

The skilled nursing facilities that thrive in coming years will be those that combine clinical excellence with robust financial operations. By choosing the right billing partner. You position your facility for lasting sustainability. Optimize PDPM payment accuracy through professional outsourcing, and dedicate your resources to the residents who depend on your services.

Major Industry Leader

Ready to optimize your skilled nursing facility’s financial performance? Partner with Aspect Billing Solutions, the leading skilled nursing facility billing company for SNFs nationwide. From PDPM reimbursement optimization to comprehensive SNF revenue cycle management. We handle the complexity so you can focus on resident care. Contact us today for a complimentary revenue analysis and discover. How our skilled nursing medical billing services expertise can maximize your facility’s reimbursement!