When Michael Mayer, Chief Information Officer with Americare, joined the organization, the company was managing clients and employees with both paper and an older software system for the Licensed Agency. These systems required a tremendous amount of manual intervention which was both labor-intensive and inefficient. As an organization that not only provides short term care themselves, they also have a large network of contracted providers to deliver long term home care services. Because of this, they act as a payer, case manager, and provider. Americare’s environment is further complicated by the fact that additional programming logic is necessary because the episodic payment requirements for Medicaid differ from that of Medicare.
In order to provide the best patient care and stay competitive within the marketplace, Mayer and the executive team recognized the need to strengthen its visibility and oversight to the delivery of services by agencies within the network. Their strategy included enterprise-wide improvements in the key areas of clinical and operational automation, home care visit verification and claims management. Mayer and the Compliance team saw this strategy as the most expeditious way to prevent fraud, waste and abuse (FWA) and drive more profits into the business. What they didn’t realize was the additional tangential benefits this key initiative provided to the organization, the provider network and the patients being serviced.