LTC Clarified: Weekly News, Insights & Connections

The Patient-Driven Payment Model (PDPM) significantly changed skilled nursing facility (SNF) reimbursement under Medicare by shifting reimbursement from therapy service volume to residents’ clinical characteristics, While CMS achieved the goal of reducing incentives tied to therapy minutes, this payment model introduced new compliance, fraud, and abuse risks centered on coding accuracy, documentation integrity and clinical classification that draw scrutiny from regulators, auditors, and enforcement agencies. Recent OIG guidance emphasizes the need for SNFs to strengthen compliance programs, auditing practices, and documentation processes.

This 6-hour comprehensive training is designed to move beyond basic PBJ submission and into real-world application, audit readiness, and risk mitigation. Learn More

Q: Medical marijuana is legal in our state, and a new resident has a physician's certification for its use. Are we required to allow the resident to use medical marijuana in our facility?

This full-day training will focus on restorative nursing programs (RNP) by reviewing program fundamentals including the types of programs, RAI definitions, and regulatory requirements. Learn More

AUGUST: Check out upcoming webinars in August!

This training, designed for individuals new to ICD-10 coding in nursing facilities, will assist you in gaining the knowledge and skills necessary to accurately assign ICD-10-CM codes for clinical and billing practices. Learn More

In the News

PBJ Deadline Approaching

August 14, 2026 is the deadline to submit Payroll Based Journal (PBJ) data for Quarter 3 (April 1–June 30, 2026). As a reminder, the PBJ transition to iQIES begins August 17, 2026. Providers and vendors much create a HARP account and request PBJ specific roles in iQIES. Prepare for this transition by:

• Register for HARP if you don’t already have an account 
• Request PBJ roles in iQIES early — approval is required before you can use PBJ functionality 
• Review workflows for data preparation, payroll validation, and CMS submission processes 
• Train staff on iQIES access, file uploads, and report navigation. Join Proactive August 19^th for a full day virtual workshop on PBJ Mastery
• Check vendor readiness if you use third-party PBJ tools 

Reminders for Employee Linking in PBJ

• Add new employee IDs to the system before linking.
• Link employees as soon as you know about changes.
• It's okay to link employees before assigning hours.
• Links are active when your file is accepted with no errors.
• Check the employee report to make sure you linked the right people.
• System Employee IDs in QIES will move to iQIES during the transition.
• QIES linking - use the current Federal Fiscal Quarter (Quarter 3) for PBJ link file submissions through August 14, 2026.
• iQIES linking - Quarter 4 submissions start after August 17, 2026. PBJ link file submissions will be accepted in iQIES on August 17, 2026.
• Templates and more information on linking can be found in the downloads section here. 

For additional assistance email the iQIES Service Center at iqies@cms.hhs.gov or contact the iQIES Service Center at (800) 339-9313, Monday through Friday, 8:00 AM–8:00 PM ET. You may also request assistance via secure chat or schedule a call through CCSQ Support Central. Please note that Chat support is currently limited to 9:00 AM-5:00 PM ET, Monday through Friday. Learn More

CMS Fraud Enforcement Authority and AI Drive Oversight

Federal officials have announced a major expansion of CMS's fraud enforcement authority that could significantly impact Medicare and Medicaid providers, including skilled nursing facilities.

CMS will have new authority to exclude providers from federal healthcare programs, creating what officials describe as a "force multiplier" for fraud enforcement. AI and advanced data analytics will play a larger role in identifying billing patterns and providers considered at higher risk for fraud before payments are made. The agency reported:

• A 40% increase in provider/supplier revocations during the first quarter of 2026 (1,413 revocations).
• More than 27,000 Medicare claims denied in Q1 for failure to meet Medicare requirements.
• Hundreds of providers flagged through fraud detection analytics.

Action items for SNFs should include routine exclusion screening for employees, contractors, medical directors, vendors, and business partners, strengthening documentation practices to support medical necessity and billing accuracy, and monitoring billing trends and quality metrics for unusual patterns before CMS identifies them. Continued proactive auditing of coding, claims, and documentation is also essential. Contact Proactive for more information on how we can support compliance efforts. Learn More

July Five Star Update Impacted Many Facilities’ QM Star Rating

CMS’s July 2026 Five-Star update raised the Quality Measure (QM) rating thresholds, meaning some facilities may see a QM star-rating change even when their underlying performance has remained stable. The updated 5-Star Preview Reports are now available in IQIES and should be reviewed closely. For example, a facility with 1,482 total QM points would have received a 5-star QM rating under the prior thresholds, but falls within the 4-star range under the revised cut points. This change reflects a higher national benchmark—not necessarily a decline in the quality of care or the facility’s actual QM results. Contact Proactive for assistance in reviewing and developing an action plan to achieve/sustain your 5-Star rating.

Contact Proactive LTC CareConnect for same-day access to seasoned clinical experts providing guidance to stabilize situations, reduce risk and move forward with confidence.