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Managed Healthcare
- Establish and implement policies and procedures for provider/payer relations, contract administration and review for the start-up of the Health Plan of San Joaquin
- Structure and align at-risk incentives between medical groups and hospitals
- Assessment, profiling and tracking of contract performance by implementing contracting Information System with linkages to billing software
- Increase net revenue in base rates with non-rate related negotiations
- Develop and negotiate network of providers and hospitals for Omni Healthcare, the Health Plan of San Joaquin, Stanislaus County – Department of Health Services with Blue Cross of California, and UCSD Health Plan
- Analyze legislation, regulations and public policies and recommend necessary safeguarding language
- Negotiate provider/payer contracts for both commercial and Medi-Cal health plans
California Medical Assistance Commission Negotiations
- Over 300 contracts negotiated for and with the Commission
- Thorough understanding of the open and closed door policies and procedures of the Commission
- Thorough knowledge of the discretionary and optional exceptions offered to a few hospitals
- Lead negotiator for the start-up of the State’s Geographic Managed Care implementation program in Sacramento, CA
- Successfully negotiate major increases even during State budget crises and successfully terminate contracts without losing revenues/days thus securing cost reimbursement (interim rates) and enhancing revenues
- Negotiate and file an appeal with Centers for Medicare and Medicaid Services to open Health Facility Planning Area due to insufficient bed capacity under contract and the burden on beneficiaries for unreasonable travel times exceeding community standards
Medi-Cal Appeals
- Successfully expedite Medi-Cal provider number assignment
- Successfully resolve Medi-Cal retroactive eligibility appeal case and recoup major financial liability to Health Plan
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Successfully resolve Medi-Cal eligibility related matters with county eligibility workers thus financially absolving hospital from incurring a major uncompensated care burden
- Successfully resolve denied Treatment Authorization Requests (TARs) due to transfers and medical necessity appeals before reaching second level appeals
- Negotiate and recoup over $12 million disputed claims from the State Department of Health Care Services
Community Needs Assessment – Access vs. Accessibility
- Evaluate community benefit plans and commitments by nonprofit health care institutions pursuant to Office of Statewide Health Planning and Development (SB 697) requirements in California
- Conduct and evaluate local community stakeholder input for access and community needs assessment plans for an urban-rural county through interviews, surveys and focus group meetings.
- Offer recommendations and road map for negotiating private-public partnership to expand access to public health, mental health, and dental services
- Design methodology for defining the scope of access to health care problems
- Commission Medi-Cal eligibility and paid claims studies, and data from the Office of Statewide Health Planning and Development as resources for determining benchmark access parameters
Governmental Relations and Public Policy
- Change the State’s policy regarding the methodology used in calculating the disproportionate share hospital list under SB 855, thus assuring the qualification of a hospital to be designated as a disproportionate share hospital
- Assist in Intergovernmental Transfer (IGT) discussions and policy
- Address and resolve public policy concerns for pass-through savings certification by the California Health Facilities Financing Authority (CHFFA) with respect to perceived need for a Medi-Cal contract
- Change the State’s policy in defaulting American Indians into managed care health plans in Two Plan Medi-Cal Managed Care Counties
- Successfully changed Medi-Cal Field Operations policy regarding Treatment Authorization Request (TAR) denials in closed Health Facility Planning Area recouping payment for over 100 denied appeals, many past 6 months
- Resolve hospital licensing and certification issues with State agencies
- Provide competitive research and governmental relations services with State agencies regarding Knox-Keene Act (State HMO license) inquiries and filings
Expert Testimony and Litigation Support
- Expert testimony in contract negotiation disputes for appealing recoveries
- Successfully guide litigation strategies, one case resulting in favorable out of court settlement after opposing party lost an Administrative Law Judge decision regarding out of network provider reimbursement rates
- Successfully debunk the errors and misrepresentations of State witnesses with testimony and targeted subpoenaed documents resulting in favorable Administrative Law Judge decision
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