CMS-approved RAC audit activity now includes a complex review focused on therapy claims billed with the KX modifier. For providers billing Medicare outpatient therapy and professional services, this is an important development to have on the radar. The review applies to physical therapy, occupational therapy, and speech-language pathology claims. Auditors will be looking at whether … Continue reading
Over the past several years, CMS has added important guardrails intended to bring more accountability and consistency to managed care. Providers expected that to make the landscape easier to navigate. Instead, many are finding the opposite. Denials still feel inconsistent. Prior authorization requirements still create delays and frustration. Requirements vary from plan to plan. And … Continue reading
Maureen McCarthy presented Managing Managed Care at AAPACN on March 19, offering practical strategies to help providers navigate today’s complex managed care landscape. To download a copy of the session handouts, please complete the form below. If you have questions after reviewing the materials—or would like expert guidance or a second set of eyes—our team … Continue reading
St. Patrick’s Day is often associated with luck.☘️ But anyone working in skilled nursing or post-acute care knows that success doesn’t come from luck. It comes from doing the right things consistently; even as regulations shift and reimbursement models continue to change. At Celtic Consulting, we work alongside providers across the country, and the organizations … Continue reading
Strong reimbursement and defensible documentation don’t happen by accident, they require alignment. During Maureen McCarthy’s presentation for the American Association of Post-Acute Care Nursing Annual Conference, we discussed how small documentation gaps between nursing, therapy, and MDS can create outsized risk during audits and managed care reviews. To support that conversation, we’re sharing our Pre-ARD … Continue reading
Skilled nursing leaders across Connecticut are preparing for an important shift: the transition to PDPM for Medicaid reimbursement. While the payment model itself is changing, the real challenge for many facilities isn’t simply understanding PDPM, it’s ensuring that current clinical processes, documentation practices, and interdisciplinary workflows will perform well under the new system. That’s exactly … Continue reading
PDPM reimbursement, quality reporting, and survey outcomes are more connected than ever; and many of the same MDS items sit at the center of all three. To help skilled nursing facilities proactively identify areas of vulnerability, we developed a complimentary assessment tool that aligns high-risk CMS F-tags with Patient-Driven Payment Model (PDPM) audit risk areas. … Continue reading
Being selected for MDS data validation can feel stressful, but it’s manageable when your facility has a clear plan. This guide walks SNF leaders and staff through the steps from notification to record submission. Pre-Validation Readiness: Questions to Ask Now Even before your SNF is selected, asking the right questions can save time and prevent … Continue reading
CMS has announced the start of the Skilled Nursing Facility (SNF) MDS Data Validation Process, with validation beginning January 1, 2026 and provider notifications issued mid-January 2026. SNFs will be randomly selected for validation, and notifications will be delivered through iQIES. While selection is not performance-based currently, preparation is critical, particularly because failure to meet … Continue reading
Skilled nursing facilities are being asked to respond to something entirely new, and understandably, many are struggling to wrap their arms around it. The Long-Stay Antipsychotic Medication Quality Measure is CMS’s first-ever hybrid quality measure, blending MDS data with claims from outside providers. That alone makes it different. But what’s proving most challenging for SNFs … Continue reading