HISTORY

Eventually, Medicare and Medicaid rules and regulations became my specialty. While working for Arthur Andersen & Co. in 1962, I was assigned to the Blue Cross of America insurance company account to audit member hospitals’ cost reports.  That assignment changed in 1964 when Congress passed the Medicare/Medicaid law.  In 1967, we were given the task of rolling out the new Medicare law in hospitals and in 1968 Medicare and Medicaid in nursing homes.  In 1969 through 1974 I was a partner in two other CPA firms where I was in charge of the health care practice.  From there I started my CPA firm specializing in hospital and nursing home Medicare and Medicaid payment regulations and the underlying accounting, software and consulting.

During the 1970’s, 80’s and 90’s my firm was assisting our clients in billing, documenting and appealing claims denials. The problem was the Federal Government under the auspices of the Department of Health Education and Welfare(HEW) began to deny nursing home Medicare claims for lack of documentation of medical necessity for skilled nursing Medicare patients.  This means the nursing home would provide the care, incur the cost, then the government wouldn’t pay them. Or pay them and take it back leaving the facility losing money on care they had provided.  This was done on a technicality that the nursing homes couldn’t prove that the care met the skilled nursing standards due to poor recording keeping or lack of knowledge on what didn’t qualify as reimbursable care.  During that time, my CPA firm was also managing skilled nursing facilities and developed software to comply with the tightening rules and interpretive guidelines of the government.   In 1968, The Federal court issued a decision that the government’s interpretations of medical necessity was illegal and forced HEW to change the interpretation for the future and repay $360 million that they had disallowed.

In 1987, my firm took over management of Fox Valley Convalescent Center and I became the licensed Administrator. We brought in our software tools and began to improve the documentation and proof for overturning any denials by appealing to the Social Security Administration (SSA) that was responsible for making sure the Medicare beneficiaries received their entitled coverage.  At Fox Valley we began to implement better therapy procedures meeting the government guidelines, based on my knowledge of the regulations.  In doing this we also developed our work flow assignment system for getting the nurses and therapists to document their interventions as they provided them … making sure that the outcomes were also documented showing that the patients were improving, which was another reason that claims were denied.  Based on two Federal court cases we overturned 100% of our denials through the appeals and were able to get more coverage for physical and speech rehab of strokes and heart attacks and restorative nursing for walking, eating, dressing, bathing, grooming, toileting, cognition and speaking due to impaired functioning caused by chronic diseases.  This is when we first systemized our 12 habits for healthy aging …  by putting in the patient’s care plan the aspects of aging that were to be restored so they could return home … not stay the rest of their lives, on Medicaid.  We called it holistic care for the body, the mind, the heart and the spirit.  The four “R’s” of care were recovery, rehab, restore function and reintegrate the patient back into the community.

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