SOFTWARE SOLUTION DEVELOPED BY JERRY RHOADS AND PROGRAMMED BY KIP RHOADS (continued from previous post)

The design of the Caregiver Management System (our software for managing the care, documentation and billing) was based on my experience at Arthur Andersen in programming cost accounting systems for our clients. The components of the system were for setting up a separate account for each patient and using the care plan, using our standardization dictionary, to get the doctor’s diagnosis that triggered standardized problem statements that could be selected for each patient.  Medicare regulations required that medical necessity result from problems treated in the hospital and continuing in the skilled nursing facility.  By focusing on the patient problems, the system would provide options for treatment and the physician could order medications, treatments, therapies and recommend discharge possibilities.  The nurses and therapies would select the specific interventions and treatments to rehabilitate and restore the patients functioning so they could walk, talk, feed themselves, dress themselves, groom themselves, toilet themselves, make decisions so they could be discharged back to their families’ responsibility in the community.

It was this system that we computerized as a software tool for a Nurse or Therapy Case Manager in each of our consulting clients and our managed facilities to manage the staff assignments and document the processes and audit the documentation for compliance with the Medicare/Medicaid rules and regulations.   Despite the court cases the government Fiscal Intermediaries (insurance companies) reviewed more and more submitted claims and the denial rates rose to 40% of claims filed for reimbursement. During the 1990’s we implemented our system in our clients’ operations, in our facilities that we managed and eventually, in 2009, those that we owned.  Our success rate for overturning the denials was 100% due to the documentation and the support for the doctors’ orders and the nurse/therapist treatments was impeccable.

Over a period of twenty years we implemented the system in 140 skilled nursing facilities (some attached to or affiliated with hospitals) in 22 different States around the country.  During this time, we had over 100,000 claims approved and only 285 denied of which all were overturned in appeal.  Under the corporate banner of Caregiver Management Systems, Inc. Shari, Kip, my son and I were the recognized experts in how the make Medicare and Medicaid work for the providers of care under the onerous government regulations that weren’t following the law or the courts orders.   In 1999 the government changed the rules to enable insurance companies to sell Medicare policies that were intended to reduce the expenditures and so-called fraud and abuse by the providers of care.  The Part A program payments were for hospitals, nursing homes, home care and hospice, Part B was for physicians and equipment payments and the new Part C was for HMO managed Medicare and Part D for prescription drugs for Medicare and Medicaid recipients.  And denials accelerated and the denials were to handled by CMS (Centers of Medicare and Medicaid Services) the paying agent for the Medicare and Medicaid; this illicit rule was imposed by the government to reduce their expenditures that were bursting the budget.   The denials accelerated in hospitals to the point there are 800,000 unpaid claims ($50 billion) hung up in appeals. Prevention of denials by using our system, if implemented in the providers operations, would solve this problem but Obama Care and now Trump Care still do not deal with the underlying problem; what the providers don’t provide (rehab and restorative care) but continue to indiscriminately raise their prices and are not accountable for the cost of treating recurring illnesses rather than preventing chronic diseases in America’s aging population.

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