Surprisingly, most SNF claim denials are not due to medical necessity but documentation errors. In 2023, 79.1% of improper payments were caused by insufficient documentation alone. Other major issues include delayed responses to medical record requests and coding mismatches in HIPPS and MDS data.
To prevent these errors, SNFs must focus on auditing, reviewing, and strengthening their claim submissions process. This blog breaks down the most common SNF billing errors and explains a preventive auditing framework that helps facilities reduce denials, improve compliance, and safeguard revenue.
Common Errors That Cause SNF Claim Denials
SNF billing involves many steps — from patient admission to final claim submission. Errors in any of these stages can lead to claim rejections or payment delays. Below are the most frequent problem areas:
1. Pre-Submission and Documentation Errors
1.1 Missing or Late Physician Certification
Medicare requires physicians to certify that a patient needs skilled care and renew that certification on time. If these certifications are missing or late, the claim is immediately denied.
1.2 Missing or Incomplete Physician Orders
Every service — therapy, wound care, or diet change — must have a valid physician order. Missing or undated orders make payers doubt medical necessity, leading to claim denials.
1.3 MDS and HIPPS Coding Mismatch
The Minimum Data Set (MDS) determines the HIPPS code used for billing under the Patient-Driven Payment Model (PDPM). If the MDS data (like diagnoses or therapy minutes) doesn’t match the patient’s chart, payers view it as an inconsistency and may deny the claim.
1.4 Missing 5-Day or Discharge Assessments
Failure to submit required 5-day or discharge MDS assessments on time leads to automatic rejections. Every Medicare stay requires these assessments to be completed and accepted by the state database.
2. Coding and Billing Errors
2.1 Incorrect Diagnosis or Procedure Codes
Using the wrong ICD-10 or procedure code is one of the top causes of SNF billing denials. The claim must accurately reflect the patient’s documented condition.
2.2 HIPPS and Case-Mix Coding Errors
Errors in HIPPS or case-mix coding can cause overpayment, underpayment, or total denial. These mistakes happen when staff misinterpret assessment data or choose the wrong PDPM group.
2.3 Duplicate or Overlapping Claims
Submitting multiple claims for the same service dates is a common administrative error. Always verify the claim status before resubmission to avoid duplicate billing.
2.4 Span Date and Timely Filing Errors
Incorrect service dates or claims filed after the payer’s deadline result in instant denial. SNFs must track their billing cycles and submission timelines carefully.
3. Post-Submission and Appeals Errors
3.1 Delayed or Incomplete Appeals
Even valid denials go unresolved when appeals are filed late or without full documentation. Missing therapy notes or certifications weaken your appeal and reduce recovery chances.
3.2 No Root-Cause Analysis of Denials
When the same denials keep recurring, it’s often because the root cause—like a documentation gap or communication breakdown—was never fixed. Analyzing these causes helps prevent future denials.
Preventive Auditing Framework for SNFs
A proactive auditing framework can identify and correct billing issues before they result in claim denials. Here’s how SNFs can structure their internal review process:
- Pre-Claim Scrub and Review
Before claim submissions, perform daily or batch reviews using claim-scrubbing tools. These identify missing information, wrong codes, or mismatched documentation early. - Sample Internal Audits
Conduct regular audits on a random sample of claims to check accuracy. Compare billing details with patient charts to confirm that services are documented and compliant. - Focused Process Audits
Target high-risk areas such as new admissions, therapy documentation, or initial claim submissions. Focused audits ensure front-end verification and coding accuracy. - Denial Trend and Root-Cause Audits
Analyze denied claims by payer or reason to identify repeating issues. Use these findings to provide focused staff training and fix weak points in the workflow. - Ad-Hoc Audits
Whenever there’s a change in payer rules or billing codes, perform quick audits. This helps the SNF stay compliant with new billing standards. - Audit of High-Risk Areas
High-risk services—like therapy, comorbidity coding, or certifications—should be audited monthly or quarterly. This ensures accurate documentation and proper reimbursement. - Post-Audit Feedback and Continuous Improvement
Every audit should end with a report summarizing errors, corrective steps, and follow-up actions. Continuous feedback helps SNFs strengthen their billing accuracy over time.
Why Outsource to 24/7 Medical Billing Services
Partnering with an expert team like 24/7 Medical Billing Services can make a huge difference in preventing SNF claim denials.
We specialize in SNF billing services, combining advanced automation with human expertise to simplify complex workflows.
Our billing experts work closely with SNF clinicians and administrators to ensure smooth coordination from documentation to final reimbursement. This personalized, end-to-end approach leads to:
- Accurate claim submissions
- Reduced denials and faster payments
- Stronger compliance with PDPM, Medicare, and Medicaid rules
When your SNF’s billing process runs smoothly, your staff can focus more on patient care rather than paperwork.
FAQs
Q1. How often should SNFs perform internal audits?
Most facilities conduct weekly pre-billing reviews and monthly random audits to catch issues early.
Q2. How do payer policy updates affect claim approvals?
Even small rule changes can trigger denials if your billing systems or staff are not updated promptly.
Q3. How does proactive auditing support compliance?
Proactive auditing ensures your SNF consistently meets Medicare, Medicaid, and private payer documentation standards, reducing the risk of denials.
Read detailed blog: https://www.247medicalbillingservices.com/blog/reducing-snf-claim-denials-common-errors-and-preventive-auditing
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