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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. Some problems are real and obvious. They are 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 is not a one-time miss. It becomes $35 multiplied by the length of stay, then multiplied again across every resident affected. Small per day, serious across a census.
See what the MDS left behindHow a daily shortfall adds up
These figures are illustrative. They show how a per diem understatement compounds over a stay and are 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. If any MDS component is understated, the total 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 NTA comorbidities on the MDS can lower the NTA tier and reduce 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 items, both the related components and the daily rate can drop.
Assessment-timing (ARD) default
PDPM payment depends on assessments being completed within the required windows. The 5-day PPS assessment sets the rate, and the Assessment Reference Date must be correct. 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. If the NTA points for a resident’s true comorbidity burden are missed, or an SLP condition is not captured, the component drops. That lowers the daily rate paid across 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 specific case mix before publishing figures. Actual exposure depends on the components affected and length of stay.
Bandwidth, not effort
Your team is not failing. They are buried in MDS completion and clinical compliance while per diem payments often go unaudited.
The "paid per-diem" blind spot
Your team chases denials; When a per diem posts, the file usually closes, even if the MDS that set the rate understated the case mix for the entire stay.
No MDS-to-payment reconciliation
Few facilities check whether the paid case mix matches the clinical record, so an understated component is often accepted as the correct 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, with no software change and no disruption, and add reviewers who compare the assessment against the clinical record.
ClearView operational visibility
Our ClearView dashboard flags when a stay paid below the case mix supported by the MDS and chart, or when a stay defaulted because of a timing issue, 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 handle targeted corrections and appeals with the documentation needed to support the correct per diem.
Payer & MAC pattern mapping
We track which payers or MACs default your stays or downgrade components, then pursue systematic corrections instead of treating each stay as a one-off issue.
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. For a lighter review, pull 10 recent Part A stays, including routine, high-acuity, and default-rate stays. Redact the identifiers, and we will show the component gaps and timing defaults live in 15 minutes using your own data.
- 1 · Pull 10 stays awith a mix of routine, high-acuity, and default-rate stays from Medicare or your top Medicare Advantage plan.
- 2 · Redact identifiers, including names, dates of birth, and Medicare numbers. We work from HIPPS codes, case mix, dates, and payment amounts.
- 3 · Send the redacted stay data securely through our portal before the call.
- 4 · Review the results live to see where an NTA or SLP component was understated, an ARD window was missed, or eligibility was miscounted.
Request received.
Thank you. A member of our team will review your information and be in touch within one business day. We look forward to showing you what your practice should be collecting.
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 one component can quietly underbill 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, with no software change and no disruption.
What is the 10-stay blind teardown?
The 10-stay blind teardown is a focused review using your own data. 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. There is no bulk PHI upload.
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 inside them in 15 minutes.