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PDPM per-diem
five case-mix components
MDS-certified reviewers
assessment & chart audit
Medicare Part A & MA
skilled & managed
Per-diem recovery
on stays marked paid
When one rate pays for every day, a small error compounds.
Ask a facility about revenue-cycle pain and you'll hear MDS accuracy, PDPM optimization, and audit risk. Real problems — the loud ones. Not the most expensive. The most expensive one clears cleanly and posts as paid: a stay paid at a case-mix below what the chart supports, quietly, on every single day.
Because the per-diem is fixed by one assessment and paid daily, a $35 daily shortfall isn't a one-time miss — it's $35 times the length of stay, times every resident it happens to. Small per day, serious across a census.
See what the MDS left behindHow a daily shortfall adds up
Illustrative figures showing how a per-diem understatement compounds over a stay — not a quote or guarantee. Actual exposure depends on your case mix, length of stay, and documentation.
Five case-mix components stack into one per-diem.
Under PDPM, your daily rate is built from five separately-scored components. Understate any one on the MDS and the whole per-diem drops — for every day of the stay.
| On the MDS | What the chart supports | What got coded | The daily shortfall |
|---|---|---|---|
| Comorbidity burden (NTA) | Higher NTA tier | Points missed | lower NTA rate |
| Cognition & swallowing (SLP) | SLP case-mix group | Not captured | lower SLP rate |
| Acuity & depression (Nursing) | Higher nursing group | Understated | lower nursing rate |
| Every day of a ~25-day stay | Full per-diem | Reduced per-diem | × 25 days |
Illustrative of how MDS under-capture lowers the per-diem across a stay; component scoring, case-mix groups, and rates are set by CMS and change.
Five ways a per-diem gets quietly understated.
SNF billing is a regulatory maze of PDPM components, MDS assessments, and Medicare eligibility rules. These are the underpayment patterns we find most often, on stays that already say "paid."
NTA comorbidity under-capture
The NTA component pays for the resident's comorbidity burden, scored on points from qualifying conditions and extensive services. There are dozens of qualifying items, and missing them on the MDS drops the NTA tier — lowering the per-diem for the entire stay.
SLP & nursing case-mix under-capture
The SLP component keys on cognitive impairment, swallowing disorders, and comorbidities; the nursing component on acuity, depression, and restorative care. When the MDS understates these, both components — and the daily rate — drop.
Assessment-timing (ARD) default
PDPM payment depends on assessments completed within their windows — the 5-day PPS assessment sets the rate, and the Assessment Reference Date must be set correctly. Miss the window and the stay can default to a low, provider-liable rate.
3-day qualifying stay & benefit-period errors
Medicare covers skilled care only after a qualifying 3-day inpatient hospital stay, and the benefit period and 100-day count must be tracked. A miscounted qualifying stay or benefit period causes denials and takebacks.
Interrupted-stay & coinsurance transition
The interrupted-stay policy, and the shift from full Part A (days 1–20) to coinsurance (days 21–100), create transitions where days get dropped, misapplied, or billed to the wrong payer.
One component understated, paid short every single day.
PDPM stacks five case-mix components into one per-diem. Miss the NTA points for a resident's real comorbidity burden, or fail to capture an SLP condition, and the component drops — lowering the daily rate that then pays out for the entire stay.
The rates and case-mix indexes are published by CMS; you can check your paid per-diems against the MDS and the clinical record.
See it on your own staysOne component, every day of the stay
Illustrative figures; PDPM per-diem rates and component case-mix indexes are set by CMS — confirm current rates and your case mix. Actual exposure depends on the components affected and length of stay.
Bandwidth, not effort
Your team isn't failing — they're buried in MDS completion and clinical compliance while the per-diem payments go unaudited.
The "paid per-diem" blind spot
Your team chases denials; a per-diem that posts closes the file — even if the MDS that set it understated the case-mix for the entire stay.
No MDS-to-payment reconciliation
Few facilities check that the paid case-mix matches the clinical record — so an understated component is simply accepted as the rate.
No assessment-timing tracking
Without a system watching ARD windows, a missed assessment defaults the stay to a low rate that nobody flags.
We reconcile every stay back to its MDS.
Seamless workflow integration plus MDS-certified reviewers. We work inside your existing facility software — no software change, no disruption — and counter rigid payer rules with people who read the assessment against the clinical record.
ClearView operational visibility
Our ClearView dashboard flags when a stay paid below the case-mix its MDS and chart support, or defaulted for a timing miss — without changing how your staff logs in.
Expert MDS & chart audit
Flagged stays route to our MDS-certified reviewers, who work inside your system to read the assessment against the clinical record, verify the NTA/SLP/nursing capture, and check the ARD schedule.
Targeted correction & appeal
We pursue the MDS correction or the appeal — with the documentation that supports the correct per-diem.
Payer & MAC pattern mapping
We track which payers or MACs default your stays or downgrade components, and pursue systematic corrections — not just one stay at a time.
Who We Serve?
Revenue integrity and full-cycle billing for skilled nursing.
Freestanding skilled nursing facilities
SNFs billing PDPM per-diem, most exposed to MDS component under-capture across the stay.
Hospital-based & swing-bed
Facility-based skilled care where assessment timing and eligibility create risk.
Multi-facility operators & chains
Operators needing consistent MDS auditing and payer-pattern mapping across facilities.
SNF + rehab programs
Facilities with heavy therapy and restorative programs where SLP and nursing case-mix capture matters most.
Your resident data, handled properly
A BAA is executed before any data is shared, and everything is handled in a controlled, auditable environment.
No PHI upload. Bring us 10 stays.
Moving resident records to a new vendor is a compliance hurdle. The lighter version: pull 10 recent Part A stays — routine, high-acuity, and default-rate — redact the identifiers, and we'll show the component gaps and timing defaults live in 15 minutes, using your own data.
- 1 · Pull 10 stays — a mix of routine, high-acuity, and default-rate stays from Medicare or your top MA plan.
- 2 · Redact identifiers — names, DOB, and Medicare numbers come out; we work from HIPPS/case-mix, dates, and amounts.
- 3 · Send securely — the redacted stay data goes into our secure portal before the call.
- 4 · Live reveal — where an NTA or SLP component was understated, an ARD window was missed, or eligibility was miscounted.
Book your 15-minute teardown
We'll confirm a time within one business day.
Common questions.
How does PDPM create underpayments?
SNFs are paid a per-diem set by the MDS across five case-mix components (PT, OT, SLP, Nursing, NTA). Because one assessment drives the rate for the whole stay, understating a single component quietly underbills every day until discharge.
Which SNF patterns do you audit for?
NTA comorbidity under-capture, SLP and nursing case-mix under-capture, assessment-reference-date (ARD) timing defaults, three-day qualifying-stay and benefit-period errors, and interrupted-stay and coinsurance-transition mistakes, among others.
How do you find them?
Our ClearView dashboard flags stays paid below the case-mix their MDS and chart support; then our MDS-certified reviewers audit the assessment against the clinical record and pursue the correction or appeal that supports the correct per-diem.
Do you make us change our software?
No. We work inside your existing facility and billing software and adapt to your workflow — no software change, no disruption.
What is the 10-stay blind teardown?
You pull 10 recent stays, redact the resident identifiers, and we show the MDS component gaps, assessment-timing defaults, and eligibility errors live in a 15-minute screen share — no bulk PHI upload, using your own data.
Do we have to switch billing companies?
No. The revenue-integrity audit works alongside your current billing, and many facilities start there before expanding.
Get paid the case-mix your care actually earned
Bring 10 stays to a blind teardown and see the MDS component gaps, timing defaults, and eligibility errors hiding in them — in 15 minutes.