CMS SNF Validation Audits Are Here: What Leaders Need to Know and How to Prepare
Insights from: Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, IPCO, QCP, ICC – Director of Reimbursement and Education
The Audit Era Is Here — and It’s Personal for SNF Leaders
If you’ve been in long-term care for any length of time, you’ve seen CMS evolve from trusting our data to verifying every keystroke. That evolution became official in September 2025, when CMS launched the Skilled Nursing Facility (SNF) Validation Program — the first-ever audit process focused on confirming that the MDS data we submit truly matches what’s in our clinical records.
But, here’s the bigger picture: The SNF Validation Program is only one piece of a much larger audit landscape that now includes MAC Additional Documentation Requests (ADRs), Targeted Probe & Educate (TPE) reviews, and program integrity audits tied to both reimbursement and quality reporting.
CMS is sending a clear message: data integrity and documentation accuracy are now the currency of compliance and payment.
The SNF Validation Program in a Nutshell
Here’s what this new validation process means for you:
- Start Date: Officially began September 2025.
- Who’s Involved: CMS and its contractor, Healthcare Management Solutions, LLC (HMS).
- Purpose: To verify that MDS-based data used in the SNF Quality Reporting Program (QRP) and Value-Based Purchasing (VBP) reflects what’s documented in the medical record.
- Audit Volume: Approximately 1,500 SNFs per year will be selected.
- Process: Selected facilities receive notification in iQIES, then have 45 calendar days to submit supporting medical record documentation for 10 sampled residents in PDF format.
- Consequences: Non-compliance can result in up to a 2% reduction in your Annual Payment Update (APU) under the QRP.
Beyond MDS Validation: Other CMS Audits to Watch
The SNF Validation Program isn’t happening in isolation. It’s part of a broader CMS oversight ecosystem that’s tightening around documentation, coding, and reimbursement accuracy.
- MAC Additional Documentation Requests (ADRs)
- Medicare Administrative Contractors (MACs) continue to issue ADRs to verify the medical necessity and accuracy of billed services — from therapy utilization to skilled level of care. When a claim is selected for review, providers must submit supporting documentation (progress notes, therapy records, physician orders, etc.) within a specified time frame. Missing, incomplete, or inconsistent documentation can lead to denied claims or recoupments.
- Targeted Probe & Educate (TPE) Audits
- CMS’s TPE program uses data analysis to target providers with high denial rates or billing anomalies. You’ll receive a probe of 20–40 claims, a review of medical necessity and coding accuracy, and one-on-one education from the MAC if errors are found.
- Repeat patterns may trigger additional rounds or escalation to full program integrity review.
- RAC and UPIC Audits
- Recovery Audit Contractors (RACs) and Unified Program Integrity Contractors (UPICs) are also increasing post-payment reviews. Their focus areas often overlap with SNF data validation—especially therapy minutes, skilled nursing justification, and Section GG accuracy. The message is consistent: CMS is cross-verifying what we code, what we bill, and what’s documented in the chart.
What This Means for NHA, DON, and MDS Leaders
- Expect Overlapping Requests – Facilities may now be juggling a SNF Validation audit and a MAC ADR simultaneously. That means documentation systems and teams must be ready to respond quickly and consistently, across multiple audit types.
- Data Accuracy Is a Team Sport – The MDS may be the final submission point, but the accuracy of that data starts at the bedside. Nursing documentation, therapy records, and physician notes must all tell the same story. For example, if your Section GG coding shows “independent,” but your therapy discharge note says “moderate assist,” CMS will spot it—and they’ll ask for clarification.
- 45 Days Is Shorter Than You Think – Whether it’s a SNF Validation Audit or a MAC ADR, the clock starts ticking fast. Leaders should designate a primary audit coordinator and backup who know how to locate records, format PDFs, name files correctly, and upload them to CMS systems.
Leadership Strategies to Stay Ahead
1. Form a Cross-Functional “Audit Readiness” Team
Bring together your MDS Coordinator, DON, QA/QAPI Lead, Medical Records, and Therapy Director. Meet monthly to review:
- Current CMS audit activity
- Recent denials or ADRs
- MDS vs. documentation consistency trends
- This team becomes your “command center” when an audit notice hits.
2. Conduct Routine Mock Audits
Pick 5–10 charts each month and validate MDS coding against clinical documentation.
Include areas most likely to be audited—Section GG, BIMS, PHQ-2 to 9, pressure injuries, therapy, primary diagnosis and active diagnosis, parenteral/IV feedings, isolation, and major falls. Document the findings, close the gaps, and share wins in leadership meetings.
3. Master the Submission Workflow
Perform a dry run of the CMS documentation upload process.
Practice converting files to PDF, labeling correctly (CCN_MDSAssessmentID.pdf), and sending securely. This muscle memory will save hours—and panic—when you get a 45-day notice. Remember to maintain an Audit Submission Log to track what’s been sent, by whom, and when.
4. Integrate Data Accuracy Into QAPI
Make “data integrity” a standing QAPI agenda item. Track internal audit scores, MDS errors, and any ADR outcomes. Use the data to guide education and celebrate improvement—because compliance and quality go hand in hand.
Remember, SNFs may file for reconsideration if they believe the finding of noncompliance is in error. A SNF that disagrees with the compliance determination, and the impending payment reduction decision may submit a request for reconsideration to CMS within thirty (30) days from the date at the top of the noncompliance notification letter. CMS will not accept any requests submitted after the 30-day deadline. Timing of your response is key!
Proactive Leadership Mindset: From Reaction to Readiness
Let’s be honest: these new audits feel like one more thing on an already full plate. Even with the current government shutdown, CMS audits are temporarily on hold. As a result, no new data or audit outcomes will appear in iQIES until the audits officially resume, it is important to be prepared!
Audits also represent an opportunity for strong clinical and operational leadership. CMS isn’t just asking for proof—they’re reinforcing what great SNFs already do: document clearly, code accurately, and stand behind their data.
By leading with preparation and transparency, you protect your facility, your team, and ultimately your residents. So, check your iQIES folder, dust off your internal audit tools, and make “validation readiness” part of your culture—not just your compliance plan.
The SNF Validation Program is here to stay, and the leaders who lean in now will be the ones defining what success looks like in this new era of data accountability.
Resources:
CMS SNF Validation Program FAQs
CMS ADR Process Overview
CMS: Additional Documentation Request (ADR) Overview
How Pathway Health Can Help
Validation Audit Expertise and Support
At Pathway Health, we understand that the new CMS SNF Validation Program has changed the compliance landscape. Our team brings real-world insight, deep regulatory expertise, and proven education tools to help your organization prepare, respond, and stay ahead of CMS validation and other audit initiatives, including MAC ADRs, Targeted Probe & Educate (TPE) reviews, RAC, and UPIC audits.
CMS has made it clear: validation accuracy now drives both compliance and payment integrity. Leaders who invest in readiness today protect their organizations from revenue loss, survey citations, and reputational risk tomorrow. Pathway Health’s Validation Audit Support Professionals deliver peace of mind, operational excellence, and confidence in every submission.
For more information on how Pathway Health can help your organization prepare for or respond to a CMS Validation Audit, visit PathwayHealth.com.
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For more information on how Pathway Health can support your organization, visit PathwayHealth.com.