Mastering Medicare Advantage: The New Era of Reimbursement Intelligence
Medicare Advantage is reshaping how skilled nursing facilities think about reimbursement. Enrollment keeps rising, and payers are creating their own level-based payment models that demand agility and insight. Among MedaSync clients this year, nearly 70% of contracts are level-based, while only about 30% still follow PDPM criteria. What worked under PDPM no longer guarantees success. Today, success depends on using AI-powered Medicare Advantage reimbursement intelligence that tracks every resident’s clinical and functional changes in real time.
The New Reality of Medicare Advantage Reimbursement
PDPM gave the industry a single set of rules to follow, but Medicare Advantage has continued to change the game. Level-based plans define their own criteria, documentation standards, and review cycles. A change in condition that would have triggered an Interim Payment Assessment under PDPM might remain reimbursement neutral in a level-based Medicare Advantage plan, and conversely, the frequency of therapy delivery or the cost of a medication may trigger a higher level for an MCO plan. Those missed updates quickly become missed revenue which is exactly where Medicare Advantage reimbursement intelligence adds value by identifying changes that affect level accuracy before billing closes.
Facilities often learn too late that they could have billed at a higher care level if adjustments had been made in time. With short lookback periods and plan-specific processes, it’s nearly impossible to catch every opportunity manually. That’s why more organizations are turning to AI-powered reimbursement tools like MedaSync — connecting care delivery directly to payer logic so that every eligible dollar is captured.
When Level-Based Complexity Meets Limited Bandwidth
In level-based Medicare Advantage plans, reimbursement is driven by acuity and service delivery. The difference between Level 1 and Level 3 can mean hundreds of dollars per day. Even the best reimbursement leaders can’t manually track every clinical change and payer requirement across multiple buildings. It’s not about knowledge — it’s about bandwidth. As MCO enrollment grows and traditional Medicare shrinks, many organizations are asking: How would our systems hold up if our managed care load doubled next year?
Manual chart reviews can take hours, often forcing teams to react to billing results instead of anticipating them. When time and staffing are limited, key level changes get missed, leading to inconsistent reimbursement and unnecessary stress. With Medicare Advantage reimbursement intelligence built into daily workflows, teams can see changes as they happen, act immediately, and protect both outcomes and revenue.
How MedaSync Turns Complexity into Clarity
MedaSync removes the guesswork. Its payer-aware intelligence reviews data from EHR, therapy, and nursing systems to flag any change that might impact reimbursement. For Medicare Advantage, it identifies residents who could qualify for higher care levels and checks that documentation is ready before billing closes. Instead of hunting for opportunities, teams get proactive alerts when action matters most.
Lionstone Healthcare, which supports dozens of skilled nursing facilities, used MedaSync to transform its approach to reimbursement. Within four months, Lionstone uncovered hundreds of new reimbursement opportunities across payers — including an average $139 per day increase from Medicare Advantage level alignment, $72 per day from Medicare IPA opportunities, and nearly a full point increase in Medicaid case mix. Regional reimbursement leaders saved more than 680 hours in manual reviews during that time.
Chief Executive Officer Adam Cusner explained that MedaSync ensures the organization captures every dollar for the care already being provided and bridges the gap between operations and reimbursement. Vice President of Clinical Reimbursement Chelsea Lowe added that her team can now review five to seven buildings in just 15 minutes — a process that once took hours. That saved time goes back to coaching, supporting care teams, and improving resident outcomes.
Expanding Intelligence Beyond PDPM
Forward thinking operators are taking what they learned from PDPM and applying it to Medicare Advantage. With AI-powered reimbursement intelligence, they can detect small but important changes in resident condition that justify mid-cycle assessments or level adjustments. This proactive approach not only improves reimbursement accuracy but also strengthens care planning and overall quality outcomes.
This mindset is becoming the new standard. Operators are moving beyond managing each payer separately and instead building unified workflows that deliver visibility across all contracts. With Medicare Advantage reimbursement intelligence at the center, they can align clinical decisions, compliance, and financial performance in one connected process.
From PDPM Precision to Medicare Advantage Agility
The move from RUGs to PDPM taught facilities to use data to reflect true resident needs. Now, Medicare Advantage pushes that even further by demanding faster and smarter decisions. MedaSync’s reimbursement intelligence helps teams stay ahead of these demands, providing continuous oversight and early alerts before revenue slips away.
By combining analytics with real-world reimbursement rules, MedaSync gives providers a complete, payer neutral view of their performance. What started as a safety net for PDPM has become a key driver of multi-payer success. Facilities can finally balance compliance and optimization without having to choose between them.
The Bottom Line: Intelligence Is the New Margin
In skilled nursing today, margins depend on insight. Every uncaptured level change or missed condition update is revenue that won’t come back. The providers succeeding under Medicare Advantage aren’t just keeping up — they’re using Medicare Advantage reimbursement intelligence to lead the way.
For organizations like Lionstone, MedaSync has become more than a reimbursement tool. It’s part of their daily rhythm, helping align care delivery, operations, and financial performance. It ensures every claim reflects the care provided and empowers teams to focus on what matters most: better outcomes for residents. That’s the future of reimbursement — intelligent, proactive, and built for every payer.
Ready to see how MedaSync helps skilled nursing organizations improve Medicare Advantage reimbursement and capture every eligible dollar? Discover how payer aware intelligence can simplify complex reimbursement and help your team perform at its best.
