Medicare and Medicaid nursing facilities under PDPM, MDS, survey, and CMP pressure — all at once.
The engagement
Corrected, defensible MDS and PDPM scoring; a stronger Five-Star and survey posture; ADR and TPE response packets answered to the contractor’s criteria; and a written read on extrapolated exposure.
Week 1 — intake: MDS/PDPM posture, survey standing, and exposure. Weeks 2–4 — MDS and documentation review against PDPM and coverage, with gaps flagged pre-bill. Ongoing — pre-bill review, MDS-coordinator coaching, and ADR/TPE response as demands arrive.
Regulatory context
The FY2026 SNF PPS rule (effective Oct 1, 2025) set a net +3.2% payment update but finalized 34 changes to the PDPM ICD-10 mappings — 33 codes moved to “Return to Provider” — so a diagnosis that priced a stay last year may not price it this year. The MDS itself changed: RAI Manual v1.20.1 took effect the same day, restructuring Section GG and other items.
Five-Star tightened in parallel — the health-inspection rating now uses the two most recent standard surveys, and previously frozen quality measures were unfrozen. The result is one record that drives payment, rating, and survey at once, tested against rules that just moved.
From revenue cycle through audit defense — each shaped to your operation.
The cross-cutting capabilities we bring to nursing facilities — Medicare and Medicaid in one workstream:
Each service shaped to the specific pressure observed.
Nursing facility operators have plenty of choices. Three reasons we win the engagements that matter:
Medicare + Medicaid in one workstream. Other firms separate them. We don't. The same chart drives both, and we review for both.
Operational fix, not consulting memo. Our CAPs are process changes with owners, workflows, and signals we audit at 60 and 120 days. The survey result moves — not the binder count.
We tell you the truth. If a CMP is likely to land, we say so. If a finding will stick on appeal, we say so. The work we do has to hold up at hearing.
Why does the MDS matter beyond payment?
Because the same assessment feeds PDPM payment, the Five-Star quality measures, and survey. A gap can cost you on all three at once.
What changed for FY2026?
A +3.2% update, but 34 PDPM ICD-10 mapping changes and a new MDS manual (v1.20.1, Oct 1, 2025) — so prior coding habits can misprice a stay.
We’re facing an extrapolated overpayment — can it be challenged?
Yes. We test the sampling and extrapolation methodology and rebuild the record claim by claim; extrapolated demands are frequently reduced on a properly built appeal.
Are you a law firm?
No — we’ve sat on both sides of the audit. Expert consultants and licensed investigators with direct contractor experience, working alongside your counsel, not in place of it. Nothing here is legal advice.
Tell us what you are up against. Scoping memo in week one, before any meaningful commitment.