Skilled Nursing Facility Medical Billing & Credentialing Services

Skilled Nursing Facility billing requires specialized expertise in consolidated billing compliance, PDPM assessment documentation, and strict regulatory requirements that general medical billing services cannot adequately address. Skilled nursing facilities including post-acute care centers, long-term care nursing homes, rehabilitation facilities, and Medicare-certified SNFs face unique revenue cycle challenges such as frequent claim denials, evolving Patient-Driven Payment Model classifications, varying payer policies regarding Medicare Part A versus Part B coverage, and intricate consolidated billing rules affecting reimbursement sustainability. Pro Health Care Advisors delivers comprehensive skilled nursing facility billing solutions designed for small to mid-sized SNFs seeking accurate claims processing, reduced denial rates, improved cash flow, and expert guidance navigating the evolving regulatory landscape governing skilled nursing and long-term care services reimbursement.

Understanding Skilled Nursing Facility Billing Complexities

Skilled nursing facility billing differs substantially from physician or outpatient billing due to prospective payment system structures, consolidated billing requirements bundling most services under Medicare Part A, and PDPM classification determining per-diem reimbursement rates that directly affect revenue approval or denial. Consolidated billing mandates SNFs bill Medicare Part A for virtually all services including therapy, laboratory tests, medications, and medical supplies provided to residents during covered Part A stays, with limited exceptions for physician services and certain diagnostic procedures billed separately under Part B.

SNFs experience significant revenue leakage through billing errors including incorrect PDPM assessment coding, improper distinction between services covered under consolidated billing versus excluded services, missing documentation supporting skilled care medical necessity, and incomplete MDS assessment submissions. Pro Health Care Advisors implements systematic quality assurance protocols identifying documentation gaps including insufficient skilled nursing notes, incomplete Section GG functional assessment data, missing therapy minutes reporting, and inadequate clinical justification before claim submission, preventing costly denials and audit vulnerabilities.

Comprehensive Billing Services for Skilled Nursing Facilities

Expert PDPM Assessment and Classification Management

Our specialists ensure accurate PDPM case-mix classification across five components including clinical category determining nursing resource utilization, functional status using Section GG scores, cognitive impairment measured through BIMS assessments, comorbidity indexes, and variable per-diem adjustments throughout benefit periods.

Consolidated Billing Compliance and Exclusion Management

Consolidated billing requires comprehensive understanding of services bundled under Medicare Part A versus excluded services billed separately including physician evaluation and management services, certain chemotherapy drugs, customized prosthetic devices, and ambulance transportation requiring proper billing coordination preventing duplicate claim submissions.

MDS Assessment Completion and Submission Oversight

Pro Health Care Advisors manages mandatory Minimum Data Set assessments including admission assessments within fourteen days, quarterly OBRA assessments every ninety days, annual comprehensive assessments, and significant change assessments when resident condition deteriorates requiring PDPM reclassification supporting appropriate payment adjustments.

Therapy Documentation and Minutes Reporting

Therapy billing under PDPM requires detailed documentation supporting medical necessity without minimum minute thresholds, accurate reporting of individual versus concurrent versus group therapy minutes on discharge assessments, and clinical rationale explaining therapy mode selections supporting Section GG functional outcome achievement.​

Strategic Denial Management Reducing Revenue Loss

Skilled nursing facilities experience substantially higher denial rates than other settings due to insufficient medical necessity documentation supporting skilled care requirements, incomplete Section GG functional assessment data triggering payment downgrades, therapy minutes discrepancies between documentation and reported data, and consolidated billing violations billing Part B services inappropriately. Common denial triggers include skilled nursing notes lacking detailed condition assessments and intervention responses, therapy documentation without complexity justification explaining skilled service necessity, PDPM assessments submitted past five-day deadlines causing payment delays, and claims rejected due to expired Medicare Part A benefit periods.

Our denial management system tracks patterns specific to SNF billing including functional assessment score mismatches between nursing GG documentation and therapy evaluations, comorbidity coding errors missing ICD-10 codes affecting case-mix indexes, and payment disputes regarding consolidated billing exclusions requiring detailed service-by-service analysis. We implement corrective action plans addressing root causes, pursue appeals with Medicare-specific clinical documentation supporting skilled care medical necessity and PDPM classification accuracy, and monitor first-pass resolution rates measuring revenue cycle efficiency.

Revenue Cycle Solutions Beyond Claims Submission

Quality Reporting Program Compliance and VBP Optimization

SNF Quality Reporting Program mandates data submission including SNF Healthcare-Associated Infections, drug regimen review measures, potentially preventable hospital readmissions, and successful discharge to community affecting future payment rates. Value-Based Purchasing initiatives tie portions of payments directly to quality performance requiring systematic outcome tracking and quality improvement initiatives maintaining competitive reimbursement rates.

Medicare Part A versus Part B Distinction

Understanding Medicare coverage distinctions prevents consolidated billing violations requiring careful identification of physician evaluation and management services billed under Part B, excluded diagnostic services including certain imaging procedures, and separately billable DME not included in SNF consolidated billing bundles. Proper coordination between SNF billing staff and external providers ensures appropriate claim routing preventing duplicate billing denials and payment delays.

Regulatory Compliance and Enrollment Requirements

The 2026 consolidated billing updates expanded CMS enrollment disclosure requirements through CMS-855A forms demanding complete ownership and control information. Missing or incorrect enrollment data causes billing privilege suspensions, claim rejections, and increased audit risk requiring systematic enrollment verification and timely revalidation submissions maintaining active provider status.

Technology Integration with MDS and EHR Systems

Modern SNF billing requires seamless integration between Minimum Data Set assessment systems, electronic health records, and billing platforms capturing clinical documentation, therapy minutes, skilled nursing interventions, and PDPM classification data supporting accurate claim generation. Automated systems reduce manual data entry errors, flag incomplete assessments before submission deadlines, and track therapy utilization supporting outcome reporting requirements.​

Partner with Specialized Skilled Nursing Facility Billing Experts

Skilled nursing facility billing complexity demands dedicated expertise understanding PDPM classification methodologies, consolidated billing regulations, and evolving CMS quality reporting requirements affecting SNF financial performance.

Our specialized skilled nursing facility billing services deliver:

• Expert PDPM assessment coding across clinical, functional, cognitive, and comorbidity components
• Consolidated billing compliance distinguishing Part A bundled versus Part B excluded services
• MDS assessment completion oversight ensuring timely submission and accuracy
• Therapy documentation review supporting medical necessity and minutes reporting
• Quality reporting program compliance maintaining VBP performance measures
• Medicare enrollment management ensuring active billing privileges
• HIPAA-compliant systems protecting resident health information
• Monthly financial reporting with case-mix index trending and PDPM impact analysis

Pro Health Care Advisors brings boutique service quality ensuring your billing team understands skilled nursing facility workflows, knows your payer mix challenges intimately, and advocates persistently for maximum reimbursement on every resident stay.