The only source of knowledge is experience.

Over 15 years of my career have been spent on the provider side of reimbursement. I have and continue to thrive on researching and discovering new reimbursement opportunities. No challenge is too big. My passion, dedication, focus, and knowledge base have resulted in the materialization of more than one hundred million dollars in new reimbursement to my employers.

My experience on the provider side is vast. I am versed in all types of hospital reimbursement whether it be an Urban Hospital, Rural Hospital, Medicare Dependent Hospital (MDH), Sole Community Hospital (SCH), Critical Access Hospital (CAH), Rural Referral Center (RRC), Lugar, Long Term Acute Care Hospital (LTCH), Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC) payment methodology.

During my tenure in provider reimbursement, I have and continue to be involved in many material financial decisions. Whether the strategy or analytics are unique or routine in nature, I am frequently asked by leadership to opine before a final decision is made.

Unique Accomplishments

• Led a team that was successful in getting multiple hospitals to qualify for the HRSA 340b drug pricing program - including registration for child sites.

• Successfully filed multiple hospital Medicare reclassification requests under various sections of the law.

• Partnered with the GME office to plan, start, report and expand new residency and fellowship teaching programs.

• Member of a leadership team tasked at creating a new LTCH hospital.

• Led a cross-functional team in the conversion from paper-based physician time studies to the creation and implementation of electronic time studies, resulting in a significant increase in Medicare Wage Index.

Routine Analytics

• Oversight of the preparations of annual State and Federal cost report and regulatory filings.

• System third party balance sheet accruals and annual year end audit.

• Completion and analytics of annual budgeted rate assumptions.

• Performed Managed Care contracting analytics to review, model, and forecast trends, market share demographics, and rates.

My career began under the supervision of the leaders at National Government Services (NGS, formerly Empire Medical Services). At NGS, I was tasked with completing cost report submission acceptance, analytics for tentative settlements, completion of final settlements, and review of reopenings. Those tasks involved teaching, non-teaching, psychiatric, rehabilitative, home health and home office cost reports.

I was a member of a number of focus groups and initiatives to help improve the efficiency and accuracy of the Medicare Wage Index reporting, the assessment and determination of Tentative Settlement adjustments, and decisions on SCH and MDH approvals.

Those initiatives fueled me to invest hours outside the normal working day in an effort to create consistent and uniform reporting among the entire Jurisdiction. As a result, I created auditable forms that were reviewed and accepted by the CMS Regional Office. The forms reduced preparation and review time which were subsequently adopted for use by the Jurisdiction over a span of 10+ years.

As a prior member of Upstate New York’s largest Health Plan, I worked in Provider Audit, Network Strategy & Administration and State Government Programs. My time there was dedicated primarily to the management and analysis of the accuracy of provider data and industry trends. I worked intimantly with leadership to jointly develop contract negotiation and risk mitigation strategies.

As a representative of the Provider Audit department I performed cost report desk and field audits. A majority of my work was committed to the review and interpretation of patient level detail. My objective was to marry the cost report data to the provider-specific contract language, with the outcome resulting in audit adjustments to the provider rates.

The time I dedicated to Network Strategy & Administration granted me the opportunity to spend a significant amount of my time with the Health Plan’s legal department. Together, we drafted contractual language for negotiations with providers. We partnered with the hospital, physician, and ancillary teams to develop standard rate sheets for contract proposals. To this day, the format and methodology of the rate sheets I created are being used across upstate New York.

Managing the State Government Programs led me to oversee the profitable market share growth strategies, compliance, network expansion, claims review, audit, reimbursement, credentialing and utilization management.