How to Choose a Skilled Nursing Facility Billing Company: 25 Questions U.S. Operators Should Ask Before Signing

A billing company can protect or quietly drain your SNF’s cash flow. Use five reports, 25 due-diligence questions and three operating scenarios to find out whether a prospective partner can actually manage Medicaid pending, Medicare Advantage authorizations, denials, resident balances and the transition risk that comes with changing vendors.

What Should You Look for in an SNF Billing Company?

Look for demonstrated long-term care experience, current billing activity in your Medicaid programs and Medicare Advantage plans, contractually defined service levels, meaningful security evidence, and a written plan for both transition and exit. A capable SNF billing company understands the workflows that make skilled nursing different from general medical billing: Medicare Part A SNF PPS claims informed by MDS assessment data, Medicaid eligibility and pending cases, managed-care authorization requirements, resident responsibility, credit balances and Medicare consolidated billing. The Patient-Driven Payment Model (PDPM) is one important part of the Medicare Part A payment environment, but it is not the whole revenue cycle.

This guide is most useful if…

• AR over 90 days is rising, especially by payer or facility.
• Medicaid-pending balances remain unresolved for weeks or months.
• Medicare Advantage denials, authorization lapses or delayed payments are becoming routine.
• Your business office has turnover, limited backup coverage or unclear ownership of follow-up work.
• You are acquiring a facility, entering a new state or considering a billing-vendor change.
• Your current billing partner cannot clearly explain denials, held claims or old AR by root cause.

How to Choose a Skilled Nursing Facility Billing Company: Start With Five Reports

Most operators enter vendor calls without their own numbers, so vendors talk about their strengths. Reverse that dynamic. Pull these reports first, then ask each vendor what it would investigate, fix and measure. They also establish the baseline you will use to hold the selected partner accountable.

• AR aging by payer and facility, with balances over 90 days clearly identified.
• Your Medicaid-pending list, including admission date, application date, effective eligibility date if known, current owner and next action.
• Denials from the previous 90 days, grouped by payer, denial reason, dollar value and appeal status.
• Unbilled and held claims, with the reason each claim is waiting and who owns the next step.
• A one-page business-office responsibility map, showing who owns eligibility, authorizations, MDS validation, billing, cash posting, appeals, patient statements and collections.

Then ask each vendor a simple question: “Looking at these reports, what would you investigate first, and what would you change in the first 30 days?”

A specialist should go straight to the Medicaid-pending list, payer-specific denials, missing authorizations or held-claim reasons. A generalist is more likely to pivot immediately to software or broad promises about collections.

What a transition review can uncover?

In a typical multi-facility review, the headline AR number is rarely the whole story. Old balances may be concentrated in a small number of Medicaid-pending cases, unresolved managed-care denials, claims held for missing documentation or resident-liability changes that were never reconciled. Separating those categories early gives the operator a usable action plan and a much better way to test whether a potential billing partner understands the work.

25 Questions to Ask a Nursing Home Billing Company Before You Sign

Ask these questions in the same order with every finalist. Request proof where noted: a redacted report, workflow, service-level agreement, transition plan, security document or client reference. A polished answer is not enough if the vendor cannot show how the work is controlled.

Does the SNF billing partner really specialize in long-term care?

Skilled nursing revenue cycle work spans Medicare, Medicaid, managed care, resident responsibility and facility operations. The OIG’s Nursing Facility Industry Segment-Specific Compliance Program Guidance identifies billing and coding risks as important compliance considerations for nursing facilities. Ask prospective vendors to show how they manage those risks in practice.

1. What share of your clients are SNFs and assisted living facilities?

Ask for a real percentage, the states where they work and examples of clients with a similar bed size and payer mix. A company that bills every specialty may still be capable, but it should prove that long-term care is a core operating competency not a sales category.

2. How do you make sure each Medicare Part A claim aligns with the MDS and supporting information before submission?

Listen for a documented pre-bill control often called a triple check that brings together the business office, MDS and clinical or therapy stakeholders as needed. It should validate assessment data, coverage days, authorization information, HIPPS codes and claim details before the claim goes out. If the vendor treats all of this as someone else’s job, probe further.

3. Walk me through a Medicaid-pending resident from admission to approval.

A strong answer includes an active pending log, an assigned owner, a documented next action, escalation for missing documents and prompt claim activity once eligibility and any retroactive effective date are confirmed under the relevant state rules. Be cautious if the vendor does nothing until approval arrives.

4. How do you handle patient liability when the state changes it after the fact?

The vendor should reconcile resident liability to applicable state notices and payer information, then correct both the claim and resident statement as appropriate. Ask how it tracks adjustments, who approves write-offs and how the facility is notified.

5. Where does your responsibility stop on resident trust funds?

The line should be clear. The facility should retain control of resident-trust-fund accounts, approvals and required notices; the billing vendor should not take custody of resident funds. Ask how the vendor supports the facility’s process and whether it understands federal resident-funds requirements.

6. How do you handle consolidated billing and Part B?

A strong answer distinguishes covered Part A stays, non-covered stays and CMS exclusions from SNF consolidated billing. Ask how the team validates outside-provider invoices, ambulance claims and HCPCS-level exclusions before payment or billing.

Can the company handle Medicare Advantage and Medicaid across your states?

Medicaid rules and managed-care workflows differ by state and plan. A vendor that is strong in one market may be learning another market at your expense. Ask for its current program and plan experience, not a general assurance that it has national coverage.

7. Which state Medicaid programs and plans do you bill today?

Ask the vendor to name the Medicaid programs, managed-care organizations and Medicare Advantage plans it actively bills in each of your states. Then request a relevant facility reference in at least one of those markets.

8. How do you track Medicare Advantage authorizations?

Look for a tracker that records authorization numbers, approval dates or days, clinical review due dates, payer contacts and escalation steps. The process should account for each plan’s authorization and notification rules before a denial occurs, not discover a lapse from the remittance advice.

9. How do you follow up on coinsurance and crossover claims?

For Medicare Part A days 21–100, confirm the applicable coinsurance amount and the responsible payer or resident balance. In 2026, SNF coinsurance is $217 per day for days 21–100 of a benefit period. Ask how the vendor distinguishes Medicaid crossover, secondary coverage, resident responsibility, state-specific rules and any documentation needed for Medicare bad-debt treatment.

10. How do you keep up with rule and rate changes?

Ask for the name or role of the person responsible, the source of updates, the frequency of internal review and an example of a recent change communicated to clients. The vendor should have a process for Medicare annual updates, payer-policy changes and state Medicaid rate or program changes.

11. How quickly can you bill for a new facility in a new state?

You want a written implementation plan covering ownership changes where applicable, payer enrollment, clearinghouse connectivity, EDI, ERA, EFT and system access. A credible timeline depends on those dependencies; a promise to bill immediately regardless of enrollment status is not a plan.

Which SNF billing KPIs, SLAs and reports will you receive?

Ask for a redacted service-level agreement and a real monthly client report. You are looking for operating discipline, not a collections total that cannot be explained.

12. Who works our account, and who covers when that person is unavailable or leaves?

Expect a named account lead, a trained backup, documented procedures by facility and a clear division of responsibility with your business office. Ask how accounts are handed over during staff turnover and how long it takes a backup to become effective.

13. Which service levels will go into the contract?

Claim-submission timelines, denial follow-up, cash posting, reporting cadence, escalation response and implementation milestones should be written into the agreement. Ask what happens if service levels are missed. Targets in a sales deck are not contractual accountability.

14. Which SNF billing KPIs will a CFO see each month?

At minimum, expect AR aging by payer and facility, days in AR, denials by root cause, Medicaid-pending status, unbilled or held claims, cash posting status, credit balances and material appeals. One total-collections number is not sufficient reporting.

15. How do you handle credit balances and overpayments?

Credit balances should be reviewed routinely, with refunds, adjustments and write-offs subject to facility approval. An identified Medicare overpayment generally must be reported and returned within the applicable federal timeframe commonly 60 days after identification, subject to the regulation’s terms and any applicable cost-report rule. Ask how the vendor escalates potential overpayments to your compliance and finance leaders.

16. Can you work inside PointClickCare or our current system?

Often, yes, but confirm it in the proposal. Ask whether the vendor can work in your existing EHR and financial systems, whether it requires a separate platform, which users receive access, and whether your organization retains administrative control and export rights.

17. What is included in the price, and what costs extra?

Spell out the scope for appeals, old AR, Medicaid applications, implementation, reporting, after-hours support, minimum fees, termination support and any technology charges. To compare a proposal against internal staffing and operating costs, see the true cost of in-house SNF billing.

How will the billing company protect resident data?

Your billing company is generally a HIPAA business associate when it handles protected health information for billing functions. HHS explains that covered entities need written assurances through a business associate agreement, and that business associates must also use compliant arrangements with subcontractors that handle PHI.

18. Will you and your subcontractors sign our BAA?

The answer should be yes. Ask for the proposed BAA, the categories or names of subcontractors that may access PHI, breach-notification timing, permitted uses of data and the process for returning or destroying data at termination.

19. Who can access our data, and from where?

Look for named user accounts, multi-factor authentication, role-based access, prompt offboarding when staff leaves, audit logs and clarity about every location from which data may be accessed, including any access outside the United States. Shared logins are a serious control weakness.

20. What independent evidence of security can you show?

Ask for a current SOC 2 Type II report, HITRUST certification, third-party HIPAA risk assessment or other independent evidence that fits the vendor’s size and risk profile. Do not treat a private “HIPAA certification” as proof of compliance; ask what was assessed, when and by whom.

21. Do you screen staff and subcontractors against exclusion lists?

Ask whether the vendor screens relevant employees and subcontractors at hire and on an ongoing cadence, commonly monthly, against the OIG List of Excluded Individuals and Entities, and whether it also follows applicable state Medicaid exclusion-screening requirements. Request the written policy and an explanation of how potential matches are resolved.

What happens during the SNF billing transition, and what happens if you leave?

Cash is most exposed when responsibility moves from one team to another. The transition plan and termination clause are not administrative details; they are your leverage before, during and after the relationship. For a full walkthrough of the handoff itself, see our guide to changing your SNF billing company.

22. Who owns our old AR?

Decide this explicitly. The new vendor may work old AR, the outgoing vendor may finish it, or it may become a separate cleanup engagement. Define the aging cut-off, payment posting responsibility, reporting and fee structure for every option.

23. How will you protect cash during the transition?

A credible plan establishes a day-one cash and AR baseline, lists open authorizations and held claims, assigns owners, tracks cutover readiness weekly and sets clear submission and cash-posting responsibilities on each side of the handoff.

24. If we leave, what do we get back?

Require a dated plan for data return, export formats, open work, historical reporting, user access and handoff support. Any termination or transition fees should be transparent and proportionate. Avoid vague or punitive exit terms, impractical notice windows, auto-renewals you cannot realistically manage and vendor claims to your historical data.

25. Can we speak with two clients, like one client who left and us?

Ask for references that match your bed size, payer mix and state footprint. Website testimonials are not references. A vendor’s willingness to connect you with a former client can be especially revealing when you are assessing the quality of the transition and exit behavior.

Three Scenario Tests to Put Every Vendor Through

Questions test knowledge. Scenarios test judgment, workflow ownership and the ability to respond under pressure. Give each finalist the same scenarios and score the answers using the same criteria.

Scenario 1: The Medicaid-pending resident

A resident was admitted 74 days ago. The Medicaid application was submitted 43 days ago, the family has not provided one missing document, and the resident has no viable private-pay source. Walk us through what your team does this week, who owns each next step, what appears on the pending log and how you bill once eligibility is approved.

What a strong answer includes

• A named owner, documented next action and dated escalation path.
• Coordination with the facility’s admissions, eligibility or social-services team.
• A process for obtaining missing documentation and escalating stalled cases.
• Clear handling of payer or resident responsibility while the case is pending.
• A prompt process for retroactive eligibility and claim submission or rebilling when approved.
• Weekly reporting until the case is resolved.

Scenario 2: The Medicare Advantage authorization about to expire

A Medicare Advantage resident has approved days through Friday. The clinical team expects the resident to remain through the following week, but the payer has not responded to the concurrent-review submission. What do you do before Friday, what do you document and when do you escalate?

What a strong answer includes

• A dated tracker with alerts before authorization or review deadlines.
• Documented proof of submission, payer contact attempts and escalation steps.
• Coordination with utilization review, clinical documentation and the business office.
• A plan that follows the specific payer’s rules for notifications, reviews and appeals.
• Clear communication of unresolved financial risk before avoidable days accumulate.

Scenario 3: The consolidated-billing dispute

An outside provider invoices the facility for a high-cost service delivered during a resident’s Medicare Part A SNF stay. The provider says the service is separately billable. How do you determine responsibility before payment?

What a strong answer includes

• Confirmation of coverage status, stay dates and the exact service provided.
• Review against CMS consolidated-billing rules and the relevant exclusions.
• HCPCS- or service-level validation where appropriate.
• Documentation of the decision and a process for resolving the provider dispute.
• A preventive control so the same invoice type does not recur.

Compare every vendor on the same page

Use LTCPro’s editable SNF Billing Vendor Scorecard to compare up to four vendors across the 25 questions, three scenario tests, reporting requirements, security controls, transition plans and exit terms.

Six Questions to Ask Every Reference

Speak with references directly. Ask the same questions of each one, then compare the answers with what the vendor promised you.

• How long did the transition take, and what did the vendor need from your facility?
• What went wrong in the first 90 days, and how did the vendor respond?
• How quickly do urgent questions receive a useful answer?
• Did AR over 90 days improve, remain flat or worsen and what drove the result?
• Would you sign with the company again?
• For a former client: why did you leave, and how did the exit process go?

How LTCPro Fits

LTCPro works with U.S. skilled nursing and assisted living facilities with 50 or more beds. Along with billing and accounts receivable, revenue cycle management and prior authorization support, LTCPro handles accounts payable, general ledger and payroll. That broader view can help operators connect claims activity with the financial reporting and business-office processes around it.

Learn more about why operators partner with LTCPro, or request a billing risk review before beginning a vendor-selection process.

Frequently Asked Questions About Choosing an SNF Billing Company

How is a skilled nursing billing specialist different from a general healthcare billing company?

A skilled nursing specialist should understand facility-based workflows such as Medicare Part A SNF PPS billing, MDS-informed claim controls, Medicaid-pending cases, resident liability, managed-care authorizations, consolidated billing and long-term care AR. A general healthcare billing company may be built primarily for visit-based physician or outpatient claims.

Can SNF billing be outsourced without changing PointClickCare?

Often, yes but confirm it in the proposal. Ask whether the vendor can work in your existing EHR and financial systems, whether it requires a separate platform, which users receive access, and whether your organization retains administrative control and export rights.

Can an outsourced billing company handle Medicaid billing across multiple U.S. states?

Yes, if it actively bills each relevant state Medicaid program and the managed-care and Medicare Advantage plans in your footprint. Ask for the states and plans it handles today, the team assigned to your account and a comparable reference in each relevant market.

Does a billing company need to sign a BAA?

When a billing company handles protected health information on behalf of a covered entity, it is generally a HIPAA business associate and needs a business associate agreement. Its subcontractors that handle PHI also need appropriate written arrangements. Review the BAA, security responsibilities, breach-notification terms and data-return obligations with your legal and compliance teams.

What SNF billing KPIs should a CFO monitor?

Monitor AR aging by payer and facility, days in AR, denials by root cause and appeal status, Medicaid-pending balances, unbilled and held claims, authorization exposure, cash posting timeliness, credit balances and material write-offs. Review trends, not only monthly totals.