This post was updated on September 29, 2026.

For skilled nursing organizations, revenue cycle performance is increasingly determined by what happens before a claim is ever submitted.

Accurate intake, authorization management, interdisciplinary claim review, and ongoing financial analytics all play a role in protecting reimbursement. When one of these processes breaks down, the result can be delayed payment, preventable denials, avoidable administrative work, or revenue that is difficult to recover — often called revenue leakage.

Heading into 2027, the stakes are particularly high as skilled nursing providers manage increasingly complex payer requirements, including Medicare Advantage authorization processes and Medicaid-pending residents. At the same time, the Patient Driven Payment Model (PDPM) continues to make the connection between clinical documentation, MDS coding, and reimbursement critically important.

A disciplined revenue cycle approach starts with four core controls: clean front-end intake, authorization tracking, a strong triple-check process, and data-driven performance management.

Key Takeaways

• Revenue cycle problems start at admission. Clean, complete front-end intake — verifying payer, eligibility, benefit period, secondary coverage, and authorization requirements — prevents the errors that become denials and aged AR.
• Authorization tracking is ongoing, not a one-time task. Treat expiration and continued-stay review dates as financial deadlines.
• The triple check is a pre-bill control, aligning the clinical record, MDS, physician orders, therapy documentation, and claim into one consistent story — increasingly important under PDPM.
• Metrics only matter if someone acts on them. Track days in AR, denial rate, clean claim rate, and net collection rate, and segment aged AR by payer.

The Four Core Controls of a Strong SNF Revenue Cycle

The sections that follow break down each control — what it involves, why it matters, and how to put it into practice.

1. Start With a Clean Front-End Intake

Revenue cycle problems often begin at admission.

A clean intake process should do more than collect a resident’s basic demographic information. Before services begin, the facility should establish a complete and accurate picture of the resident, the payer, and the coverage requirements associated with the stay.

At a minimum, the front-end intake process should verify:

• Demographics: Resident name, date of birth, address, responsible party, and other identifying information.
• Insurance and eligibility: Primary insurance, member and policy information, effective dates, eligibility status, and whether the payer is Medicare, Medicare Advantage, Medicaid, commercial insurance, or another coverage type.
• Benefit period: For Medicare-covered stays, confirm the applicable benefit period and relevant utilization information.
• Secondary payers: Identify Medicaid, Medigap, commercial secondary coverage, or other potential sources of payment.
• Prior level of care: Document the resident’s preceding setting — hospital, home, assisted living, or another post-acute setting — and capture information relevant to the qualifying stay and payer requirements.
• Authorization requirements: Determine whether the payer requires authorization and identify the specific process, deadlines, and documentation required.
• Medicaid status: For residents who may transition to Medicaid coverage, establish whether the resident is already eligible, has an active application, or should be managed as Medicaid Pending.
• Resident financial responsibility: Determine and document any private-pay balance, coinsurance, deductible, or patient-liability amount, and establish how and when it will be collected.

This information creates the foundation for everything that follows. If the payer is wrong, eligibility is not confirmed, an authorization requirement is missed, or a secondary payer is overlooked, the problem can follow the account throughout the resident’s stay.

Why Front-End Accuracy Matters: Medicare Advantage and Medicaid Pending

Medicare Advantage has made payer verification and authorization management increasingly important. Medicare Advantage insurers made nearly 53 million prior-authorization determinations in 2024, and 4.1 million — 7.7% — were denied in full or in part. The volume of determinations has grown alongside Medicare Advantage enrollment. (KFF)

Medicaid Pending cases create another layer of risk. As eligibility reviews tighten, documentation scrutiny increases, and unresolved pending balances draw closer attention, early identification and ongoing case management become especially important — an area where specialized Medicaid eligibility services can help facilities resolve pending cases before they become write-offs. For a deeper discussion, see Medicaid Pending in 2026: New Risks, Greater Scrutiny, Higher Stakes.

The takeaway is straightforward: the earlier a payer or eligibility problem is identified, the more options the organization has to resolve it before it becomes an aged receivable or denial.

2. Treat Authorization Tracking as an Ongoing Process

Authorization management should not end when the initial authorization is received.

For many skilled nursing organizations, authorization tracking needs to continue throughout the resident’s stay — monitoring the initial approval, subsequent concurrent or continued-stay reviews, authorized days, expiration dates, changes in payer requirements, and any additional documentation requested by the plan. Obtain written confirmation of each authorization and store it in the resident’s record.

A strong authorization process should answer four questions at any point during the stay:

1. Was authorization obtained?
2. What exactly was authorized?
3. How long is the authorization valid?
4. What needs to happen before the authorization expires?

That final question is particularly important. An authorization can be valid at admission and still become a revenue-cycle problem later — a resident may remain in the facility after the approved period ends while the team waits for a continued-stay determination or fails to submit the required clinical information on time.

Build Authorization Tracking Around the Entire Stay

An effective authorization tracker should include:

• Initial authorization date
• Authorization number
• Approved level of care
• Approved dates or number of days
• Next review date
• Continued-stay/concurrent review status
• Documentation submitted
• Payer response
• Denial or modification date, if applicable
• Appeal status
• Responsible staff member
• Escalation date

The lesson for SNFs is not that every authorization will be denied. Rather, authorization volume and administrative complexity require a process that actively monitors approvals throughout the stay. A good authorization workflow therefore treats expiration dates as financial deadlines — not simply administrative dates.

3. Make the SNF Triple Check a True Pre-Bill Control

The triple check should be more than a final glance at the claim.

Done correctly, it is an interdisciplinary review — typically involving MDS coordinators, therapy, nursing/clinical leadership, and the business office — designed to make sure the clinical record, MDS, physician orders, therapy documentation, payer information, and claim tell the same story. Run it on a structured, recurring cadence with defined responsibilities and ongoing staff training.

PDPM makes this particularly important. CMS implemented PDPM for SNF Part A stays beginning October 1, 2019, replacing RUG-IV and shifting the payment methodology toward patient characteristics and clinical factors, including diagnosis and other resident information. (CMS)

CMS has also specifically identified SNF billing errors associated with the transition to PDPM as an area of concern. In its 2023 SNF 5-Claim Probe and Educate initiative, CMS reported a projected SNF improper payment rate of 15.1% for 2022, compared with 7.79% in 2021, and cited potential misunderstanding of PDPM billing requirements as one factor. (CMS)

What Each Department Verifies in the Triple Check

MDS/Coding — the MDS team should verify that:

• The correct assessment is being used.
• Required MDS items are complete and accurate.
• Diagnosis coding is supported by the clinical record.
• The PDPM classification is consistent with the documentation.
• Significant changes or other assessment requirements have been addressed appropriately.

Therapy — therapy should verify:

• Therapy documentation is complete.
• Minutes and treatment information are accurate where applicable.
• Documentation supports the services reported.
• Any discrepancies between therapy records and billing information have been resolved.

Nursing/Clinical — the clinical team should verify:

• Physician orders are current and complete.
• Services billed are supported by the medical record.
• The resident’s clinical condition supports the documentation.
• Required certifications and recertifications are present.

Business Office/Billing — the billing team should verify:

• The payer on the claim matches the verified payer.
• The authorization is valid for the dates being billed.
• Patient and insurance information is accurate.
• Dates of service are correct.
• Billing requirements specific to the payer have been met.
• Secondary payer information is appropriately reflected.
• Services subject to SNF consolidated billing are appropriately bundled.
• Any known edits or exceptions have been resolved before submission.

Sample Pre-Bill Triple-Check Checklist

Use a checklist like this before releasing a claim:

The goal is not simply to catch billing errors. The goal is to establish a single, consistent story across the resident’s clinical record, MDS, authorization, and claim.

Don’t Overlook SNF Consolidated Billing

Under the SNF Prospective Payment System (PPS), most services a resident receives during a covered Part A stay must be billed by the facility rather than separately by outside providers. When an outside provider bills Medicare directly for a service that should have been bundled, it creates duplicate-billing and compliance exposure. Confirm that ancillary and outside services are appropriately captured under consolidated billing before the claim is released — a step that is easy to miss and costly to unwind.

4. Track the Right Revenue Cycle KPIs — and Act on Them

A revenue cycle dashboard is only useful if someone acts on what it shows.

Organizations should establish a small group of financial and operational metrics that are reviewed consistently, assigned to owners, and connected to specific corrective actions. Four particularly useful measures are days in AR, denial rate, clean claim rate, and net collection rate, supported by an analysis of aged AR buckets.

Days in AR

Days in accounts receivable measures how long it takes the organization to convert billed services into cash.

Richter identifies 45 days as an industry-average reference point, while also noting that the appropriate benchmark varies according to billing frequency and payer mix.

Rather than focusing only on the overall number, leadership should also ask:

• How much AR is over 60 days?
• How much is over 90 days?
• Which payers make up the oldest balances?
• Are Medicaid Pending accounts increasing?
• Are particular facilities or billing teams driving the change?

A stable or declining days-in-AR trend generally provides more useful information than a single month’s result.

Denial Rate

Denial rate measures the percentage of submitted claims or dollars that payers deny.

Richter cites an industry denial range of 6%–13% and identifies 3%–5% as a target range for skilled nursing organizations. The more important question, however, is why claims are being denied.

Track denial categories such as:

• Eligibility

• Authorization

• Incorrect payer

• Missing documentation

• Coding

• Medical necessity

• Timely filing

• Duplicate claims

• MDS/claim discrepancies
  

A declining denial rate is useful, but a declining preventable denial rate is even more informative.

A denial is not the end of the story. Build a closed-loop process: appeal eligible denials before the filing deadline, and feed the root cause of each denial back to the front-end or clinical step that produced it. Track appeal overturn rate alongside denial rate — a high overturn rate signals denials that were preventable or wrongly denied, and quantifies the revenue at stake in your appeals process.

Clean Claim Rate

Clean claim rate measures how many claims can be submitted and processed without requiring correction or additional information.

A strong clean-claim process should produce consistently high first-pass acceptance. If the rate falls, investigate whether the cause is concentrated in a particular payer, facility, workflow, employee, or claim type. Clean claims are one of the clearest indicators that front-end intake, authorization management, clinical documentation, and billing controls are working together.

Net Collection Rate

Net collection rate helps answer a fundamental question: of the collectible revenue the organization expects to receive, how much is it actually collecting?

A strong net collection rate should remain consistently high and should be evaluated alongside contractual adjustments, bad debt, payer mix, and aged AR. If collections are falling while billed revenue remains stable, leadership should look beyond the general ledger and examine what is happening in the revenue cycle.

Aged AR Buckets

Never look at total AR alone. Break the balance into aging categories — for example:

• Current
• 31–60 days
• 61–90 days
• 91–120 days
• 121+ days

Then segment those balances by payer. This can reveal problems that an overall AR number hides. A facility may have acceptable total AR while simultaneously accumulating an increasingly large Medicaid Pending or Medicare Advantage balance in the 90+ day category.

Turn Data Into Action

PointClickCare emphasizes the value of using analytics to connect clinical, financial, and operational information rather than treating reporting as a retrospective exercise. Its analytics resources highlight areas such as reimbursement, PDPM optimization, case mix, staffing, census, and operational performance.

5 Essential Back-Office KPIs Every Skilled Nursing Organization CFO Should Monitor provides additional guidance on financial metrics and benchmarks. For organizations using PointClickCare, Using PointClickCare® Analytics to Drive Better Clinical and Financial Decisions offers additional perspective on turning available data into operational decisions.

The key is to establish an operating rhythm:

• Daily: Review urgent authorization, eligibility, and high-risk AR issues.
• Weekly: Review denials, aging, pending Medicaid cases, and unresolved claim exceptions.
• Monthly: Evaluate KPI trends by facility, payer, and department.
• Quarterly: Identify recurring root causes and determine whether processes, staffing, training, or technology need to change.

How the Four Controls Work Together to Prevent Denials

These four controls are interconnected.

A clean admission reduces eligibility and payer errors. Strong authorization tracking prevents avoidable mid-stay gaps. A disciplined triple check catches discrepancies before claims leave the building. And meaningful analytics tells leadership whether those controls are actually working.

The most effective revenue cycle strategy is therefore not simply “bill faster.” It is to create a process in which accurate information enters the organization early, remains accurate throughout the resident’s stay, and is validated before the claim is submitted.

For skilled nursing organizations navigating Medicare Advantage, Medicaid Pending, PDPM, and increasingly complex payer requirements, that level of discipline can make the difference between simply generating claims and consistently converting care into collectible revenue.

Frequently Asked Questions About 2027 Revenue Cycle Best Practices

What is a good days-in-AR benchmark for a skilled nursing facility?

Richter identifies roughly 45 days as an industry-average reference point, though the appropriate target varies with billing frequency and payer mix. Tracking the trend and the share of AR over 90 days is more useful than any single month’s number.

What is a good denial rate for skilled nursing?

Industry denial rates generally range from 6%–13%, with 3%–5% a reasonable target for skilled nursing organizations. Tracking preventable denials by category matters more than the overall rate alone.

What is the SNF triple-check process?

The triple check is an interdisciplinary pre-bill review — involving MDS, therapy, nursing/clinical, and the business office — that confirms the clinical record, MDS, physician orders, therapy documentation, authorization, and claim all tell the same story before submission.

Why does PDPM make accurate MDS coding so important?

Under PDPM (effective October 1, 2019), reimbursement is driven by patient characteristics and clinical factors captured on the MDS. CMS has cited misunderstanding of PDPM billing as a factor in a rising SNF improper payment rate, so MDS-to-claim accuracy directly affects both compliance and revenue.

How Richter Can Help

Richter’s revenue cycle and accounting specialists help skilled nursing and senior living organizations tighten every stage of the revenue cycle — from front-end intake and authorization management to denial resolution, KPI reporting, and full outsourced billing support. Contact us to learn how we can help protect your reimbursement and strengthen financial performance.

Sources

• KFF — Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024

• CMS — Skilled Nursing Facility PPS / PDPM

• CMS — Skilled Nursing Facility 5-Claim Probe and Educate Review