State Case-Mix Audits Are Intensifying

As more states transition to case-mix Medicaid payment systems modeled after PDPM, audits of nursing homes are increasing - and becoming more rigorous. A recent article from McKnight’s Long-Term Care News highlights how states are using these reviews to ensure providers are accurately capturing resident characteristics that drive reimbursement.

What This Means for SNFs

• As more states adopt to PDPM reimbursement methodologies, benchmarks are able to be established as averages.

• Inaccurate, incomplete, or non-reproducible documentation is already leading to payment reductions in early-adopter states.

• Requirements vary significantly by state, making it essential for clinical and reimbursement teams to stay aligned, educated, and prepared.

• Tools like supportive documentation guides (often used in state reviews) are becoming essential references.

One of our own team members, Jennifer Napier, RN, Director of Clinical Consulting for Engage, was featured as an expert voice in the article. She emphasized a critical takeaway:

If your state publishes supportive documentation guidelines, expect them to be used in audits, including MDS, accuracy, and exception reviews.

She also noted the importance of routinely checking state resources for updates, education, and policy changes, something many providers unintentionally overlook.

Why This Matters Now

With multiple states updating or tightening their review processes this quarter, SNFs face heightened risk of missed reimbursement opportunities, or worse, unexpected payment reductions. Documentation accuracy isn’t just best practice anymore, it directly impacts your revenue.

Need Support? We Can Help

If you want help strengthening documentation practices, preparing for state audits, improving MDS accuracy, or aligning interdisciplinary workflows, our team is here to support you.