Created the managed care vision and strategies, evaluated and made recommendations to improve operations, and negotiated Commercial, Medicaid, and Health Benefit Exchange contracts with payors and providers on behalf of three large regional specialty providers in in California.
Created first Limited License Knox-Keene HMO organization (aka risk bearing organization) in the State of California.
Developed the leadership and operational structure for a Medical Foundation within a large regional health system that integrated the leadership and structures of two large capitated physician enterprises to improve the efficiency and profitability of the combined business and to position the Foundation to drive clinical integration system-wide.
On behalf of a large medical center negotiated contracts with Commercial, Medicaid and Medicare Advantage payors to improve patient volume and profitability of all lines including Medi-Cal, seniors and persons with disabilities (“SPDs”) and Dual Eligibles.
Developed narrow network, “mini-patient-centered medical homes,” gainsharing and ACO relationships with payors and providers.
Negotiated contracts with HMOs, hospitals, and medical equipment suppliers on behalf of members representing an aggregate capitated enrollment of over 2 million patients, accounting for over $2 billion in annual revenue.
Conducted an operational audit and reengineered a large health system’s MSO which administered claims for 20 managed care plans that processed approximately 400,000 claims within 18 months, and included a third party administrator, 2 IPAs and one medical group, and 2 self-funded plans.
Evaluated and made recommendations for a hospital to create a hospital/physician joint venture and acquire a Limited Knox-Keene HMO License.
Directed the financial and operational due diligence of a $367 million integrated delivery system including a hospital, physician group and IPA network throughout the State of California that was over 90% capitated representing in excess of 300,000 commercial and senior HMO members.
Evaluated and created value added strategies and solutions for a national Software-as-a-Service (SaaS) revenue cycle management company to expand its hospital services into physician and risk bearing organizations, and to create products responsive to the Accountable Care Act.
Wrote the strategic/operational plan for a large multistate health system which included a medical foundation, IPAs, MSOs, and a decentralized local involvement of hospitals in each region.
Created a process improvement plan to improve the financial, operational and medical cost functions for a national Commercial and Senior Insurance HMO.
Created medical groups, management service organizations, physician hospital organizations and other delivery models.
Designed the strategies and created a marketing and sales plan for an $8 billion insurance company to use decision support systems to improve financial and clinical processes throughout the United States as a value added service to retain and increase market share.
Created joint ventures between providers, payers and employers to develop private-label, super messenger-model, and other “alternative” HMO, PPO, insurance, and ERISA-qualified financing and delivery products.
Directed the spin off of an 8 physician medical group from a health system in which they were employed, including negotiations, creation of stand-alone systems and financial controls.
Evaluated and negotiated the acquisition of a $32 million, freestanding heart hospital, real estate corporation and medical group practice.
Conducted due diligence on a proposed $70 million joint venture cell therapy center to create pancreatic islet cells for implantation into diabetic patients to stimulate insulin production and eliminate the need for injections.
Redesigned processes, benchmarked performance and identified reengineering opportunities for the following functions within many managed care organizations:
Utilization management and referral authorization
Eligibility and benefits management
Redesigned billing and collections functions including creation of new policies and procedures for patient accounts receivable such as co-pays, write-offs, and patient hardship.
Created clinical informatics department in a large medical group to improve clinical outcomes, which facilitated the development of clinical process redesign and information flow to improve utilization review, quality assurance and risk management.
Created business rules for improving managed care revenue capture by mining and improving managed care enrollment and eligibility, including retroactive adds and deletes reconciliation, adjudication, follow-up, reporting and management.
Used business intelligence to mine data used for analyzing payment variances and identifying revenue opportunities on patient accounting claims including:
Accrual for Contractual Allowances
Bad Debt Reserve
Net Collectible Value