How does SeniorCRE reconcile payer remittances against expected PDPM and managed-care reimbursement?
When a Medicare 835 comes back at less than the expected PDPM rate — or a Medicare Advantage payer applies an undisclosed contractual adjustment — most operators post the cash and move on. The underpayment is never appealed, and the pattern is invisible until the same payer underpays the next 200 claims.
Detail
Every UB-04 claim has an expected reimbursement computed at submission from the HIPPS code, length of stay, and contracted rate. When the 835 arrives, the actual is matched line-by-line against expected. Variances above tolerance — by HIPPS, by payer, by plan — queue for appeal with supporting documentation already attached. Trend reporting shows underpayment patterns by payer plan and by month.
SNF operators should expect to recover 0.5–2% of net Medicare and Medicare-Advantage revenue that previously aged out as silent underpayments. AL/IL private-pay portfolios should not expect this lift — the workflow is targeted at Medicare and managed-care payers.
Key points
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https://seniorcre.com/workflows/financial/payer-reimbursement-reconciliation