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Series: Skilled Nursing Facility Reimbursement

Announced on  | Last Modified on  | Series Number: SRS-A-25-010
Status
Active
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

A skilled nursing facility (SNF) is a nursing home that provides skilled nursing care and rehabilitation services such as physical, speech, and occupational therapy to beneficiaries who need assistance after hospitalization. In October 2019, the Centers for Medicare & Medicaid Services (CMS) implemented a new payment system for determining Medicare Part A payments to SNFs. Specifically, CMS implemented the Patient Driven Payment Model (PDPM), a new case-mix classification system for classifying SNF patients in a Medicare Part A covered stay into payments groups under the SNF Prospective Payment System. Under PDPM, payment is determined by factoring in a combination of six payment components. Five of the components are case-mix adjusted and include a physical therapy component, an occupational therapy component, a speech-language pathology component, a nontherapy ancillary services component, and a nursing component. Additionally, there is a non-case-mix adjusted component to cover utilization of SNF resources that do not vary according to patient characteristics. We will determine whether Medicare payments to SNFs under PDPM complied with Medicare requirements.

There are 4 projects in this series.

Project titles will remain unpublished until projects are complete and reports are posted.

ACTIVE PROJECTS IN THIS SERIES (3)

Project OAS-25-02-115 • Announced on Jun 12, 2025

Project OAS-25-01-053 • Announced on Jul 31, 2025

Project OAS-25-02-146 • Announced on Aug 26, 2025

COMPLETED PROJECTS IN THIS SERIES (1)

Nearly All Skilled Nursing Services Provided by Pinnacle Multicare Nursing and Rehabilitation Center Did Not Meet Medicare Payment Requirements

Project A-02-22-01017 • Completed on November 14, 2025

TIMELINE

  • July 1, 2022
    Series Number SRS-A-25-010 Assigned
  • July 1, 2022
    Project Announced

    Nearly All Skilled Nursing Services Provided by Pinnacle Multicare Nursing and Rehabilitation Center Did Not Meet Medicare Payment Requirements - A-02-22-01017

  • June 12, 2025
    Project Announced

    Project OAS-25-02-115

  • July 31, 2025
    Project Announced

    Project OAS-25-01-053

  • August 26, 2025
    Project Announced

    Project OAS-25-02-146

  • November 14, 2025
    Project Complete - A-02-22-01017

    Nearly All Skilled Nursing Services Provided by Pinnacle Multicare Nursing and Rehabilitation Center Did Not Meet Medicare Payment Requirements has been marked as complete. This audit resulted in 3 recommendations.

  • Today
    3 Audits In-Progress
  • Est FY2026
    Estimated Fiscal Year for Series Completion

1 REPORT PUBLISHED

Nearly All Skilled Nursing Services Provided by Pinnacle Multicare Nursing and Rehabilitation Center Did Not Meet Medicare Payment Requirements (A-02-22-01017)
  • Pinnacle did not comply with Medicare requirements for 99 of 100 sampled claims, resulting in overpayments totaling $1.1 million, for skilled nursing services provided during calendar years 2020 and 2021. As a result, we estimated that Pinnacle received Medicare overpayments of at least $31.2 million.
  • Pinnacle incorrectly billed Medicare for skilled nursing services (1) when the medical record did not support that the associated individual was assigned the correct reimbursement rate code, (2) provided to individuals who did not require skilled nursing services, and (3) that did not meet documentation requirements.
  • The errors occurred because Pinnacle’s clinical and billing staff did not always follow its procedures to properly assign reimbursement rate codes in accordance with Medicare requirements and provide sufficient clinical review to verify that enrollees required skilled nursing services. In addition, Pinnacle did not follow its procedures to ensure that it always complied with Medicare documentation requirements.

26-A-02-011.01 to CMS - Open Unimplemented
Update expected on 05/13/2026
We recommend that Pinnacle Multicare Nursing and Rehabilitation Center refund to the Medicare program $31,227,884 for skilled nursing services claims that did not meet Medicare requirements.

26-A-02-011.02 to CMS - Open Unimplemented
Update expected on 05/13/2026
We recommend that Pinnacle Multicare Nursing and Rehabilitation Center consider conducting one or more internal audits or investigations for claims before and after our audit period based on the risks identified by this audit to identify any similar overpayments the provider might have received and return any identified overpayments to the Medicare program.

26-A-02-011.03 to CMS - Open Unimplemented
Update expected on 05/13/2026
We recommend that Pinnacle Multicare Nursing and Rehabilitation Center provide additional training to its clinical and billing personnel on its procedures related to assigning appropriate billing codes when submitting claims for Medicare reimbursement; providing enrollees only reasonable and necessary skilled nursing services; and maintaining proper documentation to support services provided.

View in Recommendation Tracker
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
-
Target Groups
Elderly
Financial Groups
-