A new report from the US Department of Health and Human Services (HHS) Office of Inspector General (OIG), issued November 14, 2025, found that nearly all sampled skilled nursing services at a nursing home in the Bronx, New York, did not comply with Medicare payment requirements. The audit examined claims submitted under the Patient Driven Payment Model (PDPM), which was implemented by the Centers for Medicare & Medicaid Services (CMS) in October 2019 to determine Medicare Part A payments for skilled nursing facilities (SNFs).
The audit was part of a broader review of skilled nursing services under PDPM, prompted by prior OIG findings that these services are vulnerable to improper payments. The purpose was to determine whether the facility’s claims for skilled nursing services complied with Medicare requirements.
OIG found that 99 of 100 claims reviewed did not meet Medicare requirements, resulting in overpayments of $1.1 million for services provided during 2020 and 2021. Based on these findings, OIG estimated total overpayments of at least $31.2 million. Errors included:
- Billing for skilled nursing services without proper documentation or clinical support.
- Assigning incorrect reimbursement rate codes for Medicare claims.
- Providing services to individuals who did not require skilled nursing care.
The issues were attributed to staff not consistently following procedures for assigning reimbursement codes, verifying the necessity of services, and maintaining documentation in line with Medicare requirements.
OIG made three recommendations to the facility:
- Refund $31.2 million to the Medicare program for claims that did not meet requirements.
- Conduct internal audits or investigations of claims before and after the audit period to identify and return any additional overpayments.
- Provide additional training to clinical and billing staff on proper procedures for coding, providing necessary skilled nursing services, and maintaining supporting documentation.
The facility did not concur with any of the OIG’s recommendations.
The full report is available here.
Compliance Perspective
Issue
Accurate Medicare billing and thorough clinical documentation are essential for ensuring compliance, maintaining appropriate reimbursement, and supporting high-quality resident care. When facilities do not consistently follow established procedures for assigning reimbursement codes, verifying clinical need, and maintaining proper documentation, the risk of billing errors and regulatory noncompliance increases. Strengthening internal oversight, staff competencies, and routine monitoring processes can help organizations reduce the risk of billing errors and support overall compliance.
Discussion Points
- Facilities should review and, if needed, update their billing and documentation policies to ensure alignment with current Medicare requirements. Procedures should clearly outline expectations for assigning reimbursement codes, verifying skilled nursing need, and maintaining complete and accurate clinical records. Facilities may also benefit from working with their consultant to conduct a focused review of existing processes or to perform targeted assessments that help identify gaps and support improvements in day-to-day compliance practices.
- Ongoing education is essential to ensure that clinical and billing staff understand the criteria for skilled nursing services, documentation expectations under PDPM, and the importance of accurate assessment and coding. Med-Net Academy offers the course Understanding and Using the Medicare Triple Check Process, which is designed to help staff improve billing accuracy for skilled services, avoid false claims, minimize denials or adjustments, ensure residents receive the benefits they’re entitled to, and better align clinical documentation with financial data.
- Regular audits help verify that policies are being followed and that claims are supported by accurate and complete documentation. These reviews should assess reimbursement code assignments, clinical justification for skilled services, and the adequacy of supporting records. Facilities may find value in collaborating with their consultant for mock surveys or targeted billing and documentation audits, which can provide an objective evaluation of compliance and assist leadership in identifying trends, areas for improvement, and opportunities to reinforce oversight through the QAPI process.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*