Beyond Therapy: How Specialty Physicians Can Drive PDPM Medicaid Success

As more states transition to PDPM for Medicaid, therapy is no longer the primary driver of case mix index (CMI). So where do providers turn next?

In this episode, Melissa Brown, COO of Gravity Healthcare Consulting, sits down with Dr. Rehan Shah, nephrologist and co-founder of CardioRenal Vision (CRV), to explore how cardiology, nephrology, and pulmonology services can transform PDPM Medicaid outcomes.

Together, they discuss:

• Why therapy-driven CMIs are declining under PDPM Medicaid
• How specialty physician programs improve documentation, acuity capture, and reimbursement accuracy
• The power of on-site care models—from dialysis to respiratory therapy—to reduce hospitalizations and boost CMI
• Practical steps for aligning physicians, MDS coordinators, and facility leadership

If your organization is preparing for PDPM Medicaid—or already navigating the transition—this episode offers actionable insights to help you strengthen performance, accuracy, and margins under the new model.

🎧 Hosted by: Melissa Brown, COO, Gravity Healthcare Consulting
📍 Guest: Dr. Rehan Shah, Co-Founder, CardioRenal Vision

Transcript

Melissa Brown (Host)

Welcome! You’re listening to Gravity Healthcare Hacks with your host, Melissa Brown — Chief Operating Officer from Gravity Healthcare Consulting and self-professed healthcare nerd.

Each month, we bring you industry expertise and tips to help keep your feet firmly on the ground in the world of healthcare.

Hello, everyone, and welcome to our podcast today! I am super excited to have a longtime colleague, Dr. Rehan Shah of CardioRenal Vision, joining us.

Dr. Shah and I have been collaborating for years now about PDPM, and recently we began working together to develop our vision for PDPM Medicaid. I can’t wait to share these tips and tricks with you.

Welcome, Dr. Shah!

Dr. Rehan Shah (Guest)

Thank you, Melissa. Thanks for having me.

Melissa Brown

Wonderful — I’m so glad to have you.

Just so our listeners understand what you do at CRV, tell us a little bit more about yourself and what the company does for skilled nursing providers.

Dr. Rehan Shah

Absolutely. My name’s Dr. Rehan Shah, and I’m a nephrologist trained at SUNY Downstate in Brooklyn, New York.

As a specialist, much of my focus used to be in hospitals and clinics. But over time, I saw major challenges in the post-acute care space.

After seeing so many high-acuity patients in the ER, I wanted to dive deeper — to understand what happens in skilled nursing and how we could help.

A colleague and friend, Dr. Ahmed, and I founded CardioRenal Vision (CRV) — starting in Florida and expanding nationwide — with a goal of being truly dedicated to post-acute care.

Our mission is to reduce readmissions (RTAs) and bring care directly to the patient — because that’s where we see the best outcomes.

Melissa Brown

Absolutely. And as you know, I’ve been living and breathing all things PDPM Medicaid.

This episode will probably come out around October 1, 2025, which is the looming deadline for states to decide on their Medicaid transition.

Some have already done it; others are delaying.

So many providers are switching — or will soon switch — to PDPM for Medicaid.

What should providers be most concerned about or thinking about with this transition?

Dr. Rehan Shah

That’s a great question.

The first big shift is that you can’t use therapy for CMI under PDPM — and that’s a big change.

We need to be more innovative and think about other ways to drive outcomes and reimbursement.

At CRV, our goal isn’t just to provide excellent clinical care — though that’s our foundation — but to be true partners at the facility level.

If we can improve outcomes, reduce hospitalizations, and at the same time help increase PDPM rates, that’s the ideal.

We focus heavily on acuity documentation — making sure high-acuity diagnoses are correctly captured.

Our specialties — cardiology, nephrology, and pulmonology — are central to this because we often find patients with undiagnosed conditions like CKD or COPD.

By accurately diagnosing and documenting these, we can directly impact CMI and reimbursement.

Melissa Brown

That’s such an important point.

Gravity recently released a PDPM Medicaid State-by-State Guide that covers these strategies in detail — and you’re exactly right about the therapy piece.

If a facility’s CMI was driven by therapy utilization before, they might see a significant drop under PDPM Medicaid.

Providers now need new drivers — and PDPM-trained ancillary physicians like those from CRV can play a huge role.

So, tell us: what is CRV doing to help facilities manage their CMI?

Dr. Rehan Shah

The key is identifying high-risk patients — those most likely to be re-hospitalized — and ensuring we’re properly diagnosing and documenting their conditions.

For example, in our pulmonary program, we conduct sleep studies and pulmonary function tests (PFTs) on-site to diagnose COPD and restrictive lung disease.

This helps ensure patients who need CPAP/BiPAP can get insurance approval and go home safely.

We also manage dialysis patients on-site and focus on collaboration between specialties.

Cardiology, nephrology, and pulmonology are deeply connected — what we call the cardiorenal approach — and that integrated care is transforming outcomes and CMI performance.

Melissa Brown

I love your comments about dialysis.

It’s such an opportunity for communities — both clinically and financially.

Patients would much rather stay in the facility than travel three times a week for dialysis.

Your model of bringing specialists on-site doesn’t just improve care — it also supports ICD-10 accuracy, documentation, and CMI under PDPM Medicaid.

So, how does CRV support documentation consistency, especially on the long-term care side?

Dr. Rehan Shah

Training is everything.

We train all our physicians, nurse practitioners, and PAs on PDPM-specific documentation — and Melissa, you’ve been instrumental in that.

For example, properly documenting shortness of breath while lying down for a COPD patient — when clinically accurate — can shift the CMI score dramatically.

We’ve added a clinical documentation specialist to our team, and we re-educate our providers quarterly.

It’s a continuous process of training, auditing, and improving documentation accuracy.

Melissa Brown

That’s so powerful.

PDPM-trained physicians make all the difference — untrained providers often have no impact or even a negative one on reimbursement accuracy.

Collaboration with the MDS coordinator is also key.

So, how is CRV partnering with MDS teams to align documentation with reimbursement?

Dr. Rehan Shah

It starts at the corporate level — setting clear documentation protocols — and continues with quarterly meetings at the facility level.

We review our notes with MDS coordinators, DONs, and nursing teams to identify opportunities for improvement and ensure bi-directional communication.

That feedback loop keeps documentation strong and consistent.

Melissa Brown

Exactly — and ensuring documentation appears within the right look-back period is crucial.

As states move to nursing and NTA-based PDPM models, repeat documentation and ongoing verification of diagnoses become essential.

So, what are you seeing now as the biggest clinical or operational levers for success under PDPM Medicaid?

Dr. Rehan Shah

It’s all about collaboration and integration.

Our best results come when specialty care, primary care, and nursing leadership work together.

Bringing all of those perspectives together drives clinical excellence and PDPM performance.

Even our conversations with medical directors have become learning opportunities — they’re eager to understand PDPM and its impact.

Melissa Brown

Let’s shift gears to respiratory therapy — one of the highest-value nursing categories under PDPM Medicaid.

What is CRV doing to establish and support RT programs in communities?

Dr. Rehan Shah

Respiratory therapy is often underutilized, but it’s incredibly impactful.

We use co-rounding — our physicians and RTs round together, just like in the ICU.

It doesn’t have to be daily; even weekly or biweekly co-rounding identifies high-risk patients and ensures proper documentation.

We’ve seen a 15% reduction in readmissions using this approach.

It improves compliance with CPAP/BiPAP, optimizes oxygen use, and creates strong clinical documentation that supports reimbursement and quality.

Melissa Brown

That’s such a stellar model.

And you’re right — states are beginning to add documentation requirements around RT and COPD, since both are high-value categories under PDPM Medicaid.

Annual pulmonary function tests and repeat documentation are just good clinical practice — but they also protect against denials and take-backs.

Now, let’s talk about Texas, one of your core states.

Texas condensed 25 CMS CMGs into only six, which means providers can’t affect CMI through depression, restorative, or section GG — only by moving up acuity categories.

How does CRV help providers in a state like that?

Dr. Rehan Shah

Great question.

It comes down to diagnosis specificity.

Too often, we see providers document “CHF, unspecified” or “CKD, unspecified.”

We train our clinicians to document systolic vs. diastolic, staging of CKD, and related comorbidities.

That precision is essential in states like Texas where acuity drives everything.

We also emphasize incentive spirometry and respiratory management to keep patients optimized — both clinically and financially.

Melissa Brown

Fantastic insights, Dr. Shah.

Listeners, I encourage you to explore partnerships with ancillary physician groups like CRV who understand the clinical and reimbursement nuances of PDPM Medicaid.

Their integrated specialty model — cardiology, nephrology, and pulmonology — aligns perfectly with PDPM’s focus areas and documentation needs.

Dr. Shah, thank you so much for joining us today and sharing how CRV’s approach helps providers strengthen CMI and outcomes under PDPM Medicaid.

Dr. Rehan Shah

Thank you, Melissa. I appreciate the partnership and everything you’ve done to educate and support our team.

Melissa Brown

Thank you, Dr. Shah.

And to our listeners — if you’d like to continue the conversation, you can find both of us on LinkedIn.

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Remember: It’s not just what you know — it’s how you apply it that makes all the difference.

See you next time.