PDPM Hidden Revenue

3 Areas Where Skilled Nursing Facilities Consistently Leave Money on the Table

****Get your Free Revenue Optimization E-Book Here ****

In Skilled Nursing Facilities, the shift to the Patient-Driven Payment Model was intended to align reimbursement with patient complexity. In practice, many facilities are delivering high-acuity care without capturing the reimbursement tied to that work.

This creates a silent revenue leak.

At SMK Medical, we consistently see facilities doing the right clinical work but failing to document it in a way that translates into accurate PDPM reimbursement. This is not about upcoding. It is about clinical accuracy, documentation integrity, and being paid for the resources you actually use.

If your daily Medicare rates are flat while labor and supply costs continue to climb, you may be leaving $30 to $130 per patient day unclaimed in three common areas.

The NTA Component: The Cost of a Missed Diagnosis

The Non-Therapy Ancillary component is front-loaded, with the highest weighting during the first three days of a resident’s stay. If qualifying comorbidities are not captured immediately, that revenue is permanently lost.

The reality
Secondary diagnoses such as morbid obesity (BMI greater than 40), malnutrition, ESRD, or complex cardiac conditions are often active but absent from the hospital transfer paperwork. When they are not captured on admission, facilities lose $20 to $50 per day per resident.

The financial impact
On a 20-day Medicare stay, a single missed diagnosis can result in $1,000 or more in lost reimbursement for one resident.

The SMK Medical solution
We implement a structured 72-Hour Deep Dive process. Your intake, MDS, and nursing teams are trained to actively query hospitals and validate active diagnoses early, before the NTA window closes.

Speech-Language Pathology: The Most Under-Coded PDPM Component

The SLP component remains one of the most misunderstood and under-captured areas of PDPM. Many facilities assume residents must have obvious cognitive impairment to qualify for higher SLP reimbursement.

That assumption is costly.

The reality
Residents with mild cognitive impairment, swallowing disorders, mechanically altered diets, thickened liquids, or food pocketing frequently qualify for higher SLP case-mix groups. When captured correctly, this can increase reimbursement by $30 to $80 per day.

The financial impact
In a 100-bed facility, missing SLP qualifiers on just 5 percent of Medicare residents can result in $4,500 or more in lost revenue every month.

The SMK Medical solution
We align SLP evaluations with nursing documentation, specifically Section K, dietary consistency, and swallow safety notes. This ensures clinical findings are supported across disciplines and defensible during audit or survey.

Nursing Case-Mix: Doing the Work Is Not Enough, You Have to Prove It

Restorative nursing, respiratory symptoms, and complex clinical care are often performed daily by staff but never translated into MDS-relevant documentation.

The reality
Symptoms such as orthopnea in residents with COPD, frequent oxygen adjustments, or ongoing skilled nursing monitoring can move a resident into a higher Nursing Case-Mix group. One documented symptom can add approximately $81 per day.

The financial impact
Capturing that single clinical detail for one resident over a standard month can be worth $2,400 or more in additional reimbursement.

The SMK Medical solution
We provide specialized documentation training for nurses and CNAs, focused on translating bedside care into compliant, MDS-ready language. The goal is to close the gap between providing care and proving care.

Stop the PDPM Revenue Leak

PDPM revenue loss is rarely caused by poor care. It is caused by poor documentation flow, missed clinical connections, and lack of cross-disciplinary alignment.

At SMK Medical, our PDPM and MDS audits routinely identify an average of $34,000 per month in previously uncaptured revenue for mid-sized facilities, simply by correcting documentation accuracy and clinical workflows.

If your facility is working harder but not seeing it reflected in reimbursement, it is time for a deeper review.

Call 313-314-8267 or schedule a consultation through SMKMedical.com to identify where your revenue is leaking and how to fix it.



SEO Keywords

PDPM hidden revenue, PDPM reimbursement optimization, skilled nursing PDPM revenue, PDPM documentation errors, MDS accuracy, PDPM NTA component, PDPM SLP reimbursement, nursing case-mix PDPM, Medicare Part A PDPM, PDPM audit services, MDS consulting services, skilled nursing reimbursement optimization

Disclaimer

The content provided on this blog by SMK Medical is for general informational purposes only and is specifically tailored to post-acute care executives, leaders, and directors. The information, including regulatory compliance guidance, reflects our understanding at the time of publication. Rules, regulations, and standards in the healthcare industry are subject to frequent change, and SMK Medical makes no representations or warranties regarding the completeness or current accuracy of the content provided. All case examples or scenarios mentioned have been anonymized and or aggregated to protect the identity of the parties involved. This blog does not constitute professional advice, consultation services, or establish a client relationship. Readers are strongly encouraged to consult with qualified professionals and verify current regulations before making any decisions based on the information presented. SMK Medical expressly disclaims any and all liability for any direct, indirect, or consequential damages resulting from the use of or reliance on this content.