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Case Study: Enhancing Medicare Reimbursement through Expert MDS Consulting with SMK Medical

Case Study: Enhancing Medicare Reimbursement through Expert MDS Consulting with SMK Medical

Posted on June 20th, 2024


A five-star facility reached out to SMK Medical for a complimentary revenue assessment. The new administrator, who had recently taken over a small nursing home, sensed discrepancies in the facility’s financial performance. Intrigued by our LinkedIn ads and driven by the need for clarity, he opted for a free email consultation. After a thorough discussion, he agreed to provide the necessary data for a comprehensive revenue assessment, setting the stage for a transformative partnership.

Challenge: Unveiling Hidden Revenue in a Five-Star Facility During a COVID Outbreak

The facility’s fiscal year 2024 Medicare data exposed critical gaps: the average rate was $592.42, with nursing and NTA (Non-Therapy Ancillary) averages at $138.76 and $76.96, respectively. Despite a significant COVID outbreak, there was no corresponding increase in the average rate, NTA points, or nursing categories. This lack of adjustment highlighted missed opportunities for capturing complex patient care needs during the outbreak.

Compared to the SimpleLTC benchmark, the facility fell short by approximately $94/day/resident. Over a seven-month period (October 23 to April 24), these discrepancies resulted in a potential loss of nearly $119,192 in Medicare reimbursements. This shortfall was due to the underutilization of PDPM (Patient-Driven Payment Model) categories and inaccuracies in MDS (Minimum Data Set) coding, which failed to account for the heightened acuity and additional services required during the COVID outbreak.


SMK Medical, specialists in remote MDS consulting and PDPM, conducted a thorough audit and analysis of the facility's Medicare billing and MDS assessments. Here’s what we uncovered:

  • Inconsistent Capture of PDPM Categories: The facility consistently underrepresented the complexity of resident care. Most stays were wrongly classified under the lowest combined NTA & Nursing categories, even during the COVID outbreak, where care complexity should have been higher. This misclassification ignored the actual acuity levels and resulted in substantial revenue losses.
  • Missed Opportunities in NTA and Nursing: Critical documentation lapses were evident. There were no recorded instances of residents receiving intravenous fluids (IVF), a common occurrence during a COVID outbreak. Proper documentation of such care could have elevated the Nursing category from PBC1 to HDE1, which would have increased the daily reimbursement rate by approximately $87/day. This oversight indicates a failure to capture all reimbursable services provided.
  • Suboptimal MDS Coding Practices: Monthly audits revealed significant inaccuracies in MDS assessments. The facility’s coding practices were subpar, failing to capture all NTA points accurately. This led to a chronic underestimation of residents’ care needs and, consequently, lower reimbursement rates. The coding inefficiencies neglected key aspects of patient care that should have been documented, thereby directly impacting the facility’s financial performance.


SMK Medical deployed its expert remote MDS consultants to address these issues. Here’s how we turned the situation around:

  1. PDPM Education and Training: We provided specialized training to the facility’s case managers, focusing on accurate coding and maximizing NTA point capture.
  2. Regular MDS Audits: Our team performed monthly audits to validate MDS assessments and ensure proper coding for all Medicare stays.
  3. Enhanced Clinical Capabilities: We worked with the facility to expand their clinical services, enabling them to accept more clinically complex residents, thereby improving their reimbursement rates.
  4. Strategic Use of IPA (Interim Payment Assessments): We advised on the optimal use of IPA to capture higher rates when appropriate.


Recognizing the urgent need for financial recovery, the administrator engaged SMK Medical to revamp their approach. Our expert remote MDS consultants employed a multi-faceted strategy to address the facility's challenges and unlock its revenue potential. Here’s how we delivered transformative results:

  1. PDPM Education and Training: We initiated a comprehensive education program for the facility’s case managers. Our specialized training sessions focused on precise coding and maximizing NTA point capture. This ensured that every aspect of patient care, especially the more complex cases, was accurately reflected in the billing process.
  2. Regular MDS Audits: SMK Medical’s team conducted meticulous monthly audits of MDS assessments. These audits were pivotal in validating the accuracy of coding for all Medicare stays. By systematically identifying and correcting errors, we ensured that the facility captured all possible reimbursement points, directly improving their revenue streams.
  3. Enhanced Clinical Capabilities: To better serve their resident population and capture higher reimbursement rates, we worked closely with the facility to expand their clinical services. This involved upgrading their ability to accept and manage more clinically complex residents. By doing so, the facility could now document and bill for a broader range of services, thereby increasing their Medicare reimbursements.
  4. Strategic Use of IPA (Interim Payment Assessments): We provided targeted guidance on the effective use of IPAs. This strategic tool was utilized to capture higher rates when residents’ conditions changed, ensuring that the facility received appropriate compensation for the increased care needs. Our advice on setting ARDs (Assessment Reference Dates) correctly enabled the facility to optimize their reimbursement rates for varying levels of resident acuity.


Through our expert intervention, the facility experienced a substantial improvement in their Medicare revenue:

  1. Increased Reimbursement Rates: Accurate PDPM categorization and proper documentation of services, especially during the COVID outbreak, led to a significant increase in daily reimbursement rates.
  2. Recovered Revenue Potential: The facility is moving forward with successfully capturing nearly $100,000 in previously missed Medicare billing opportunities over a span of seven months.
  3. Sustained Financial Performance: Enhanced clinical capabilities and ongoing audit practices ensured continued financial health and compliance, positioning the facility for long-term success.

By leveraging SMK Medical’s expertise in remote MDS consulting, the facility not only bridged its revenue gaps but also strengthened its operational efficiency and care quality.

Ready to enhance your Medicare revenue? Book your free facility revenue assessment HERE OR CALL 313-314-8267

Contact SMK Medical for a free assessment today and discover how our MDS experts can transform your facility’s financial performance.


The information provided on this blog by SMK Medical is for general informational purposes only. We are not liable for any actions that were taken based on the information provided. Please consult with a qualified professional for specific advice.

🚀 Unlock Hidden Revenue with SMK Medical! 🚀

A five-star facility was missing out on nearly $119,192 in Medicare reimbursements despite maintaining top-notch care. They turned to SMK Medical for a game-changing solution.

What We Did: 🔍 In-depth Audit: Identified gaps in MDS assessments and coding. 📚 PDPM Training: Equipped staff with expert coding skills. 🔄 Regular Audits: Ensured accuracy and maximized revenue capture. 💉 Clinical Enhancement: Expanded services to accept more complex cases.

Result: A remarkable potential recovery of $100,000 in missed billing opportunities!

Don’t let potential revenue walk out the door. Contact us today for a FREE revenue assessment! 💸

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