Strategy & Operations Analysis and Assessment
- Engaged by Market President of new Medicaid Managed Care Organization (MCO) to support transition of services from state-based to privatized model during state’s Medicaid expansion. Supported implementation of shared service model in local market to define operational needs and capabilities across network operations and claim payment functions, including: definition and implementation of provider network operations function and facilitation of “war room” environment to accelerate resolution of provider-related questions and concerns.
- Worked with COO of Medi-Cal plan to assess strategy and opportunities to shift their business administration operating model from a wholly outsourced model to key scenario variations; addressed people, process, and technology capabilities for each scenario and modeled business cases to establish viability of each go forward strategy and final board recommendation.
- Led strategic initiative for national Medicaid managed care organization to assess current operations and technology capabilities to support major growth initiatives and expansion opportunities including definition of Center of Excellence and engagement model definition across end-to-end operations for national business support. Our team’s work included review of current state operations and technology support, organizational alignment review, identification of recommendations and solution opportunities, and development of future state implementation roadmap. Our success has led to additional engagements to implement numerous recommendations and support new business expansion efforts.
- Engaged by the interim CEO of a large regional Blues plan to provide insight on problems experienced with the organization’s ability to deliver IT initiatives for corporate programs and day-to-day support. Review included assessment of IT organization, corporate initiatives, and program governance practices to identify critical areas of opportunity and provide Future State and “Quick Hit” recommendations and roadmap for implementation.
- Led operations assessment for a large regional Blues plan related to its Pharmacy Benefits Managers (PBMs) and consumer directed health product with combined pharmacy and medical accumulators; led development of new organizational structure and operating model to effectively manage product focused on resolving existing operational issues and facilitating implementations of new business accounts and carve-out PBMs through increased standardization of processes.
- Engaged by CIO of major metropolitan union to build 3 health plans under the Consumer Oriented and Operated Plan (CO-OP) provision of Healthcare Reform and ACA legislation. Facilitated team on strategic planning activities and build out of product and benefit designs to support entry into new markets and segments (small group/SHOP and individual) for on and off exchanges. Defined operational and organizational requirements for new entities. Drove development of overall program office responsibilities, procured and implemented 11 back office functions across 7 vendors, and supported key workstreams, including state-specific health exchange requirements, vendor contracting, enrollment and billing, and pharmacy and ancillary services.
Medicaid Managed Care Experience
- Led effort for Medicaid managed care organization to assess risk of new business acqusition and support implementation of business in new market; assessing network management and operations areas to identify risk areas and operational pain points, facilitating claim payment review to determine payment integrity and upstream operational challenges, defining roadmap for accelerated implementation of improvement opportunities for new line of business.
- Led and defined hospital contract analysis for Medicaid managed care insurer to identify gaps and discrepancies between hospital contracts and claims payment, which led to identification of 2.5% of claims payment “leakage” associated with reimbursement inaccuracies. Performed 18 month, all-inclusive hospital claims review to identify claims accuracy issues and provide recommendations on potential corrective actions, including reimbursement methodology opportunities, for contracting and claim payment setup. The engagement identified payment accuracy errors, including over and under payment issues, of over $12 million in net overpayments to its participating hospitals.
- Worked with large, national Medicaid managed care organization on proposal to expand services into new strategic market; directed client in development and communication of critical “win themes” for proposal, worked with key resources to develop proposal content, and provided key insights on Medicaid requirements and unique market needs.
- Worked with growing health services company focused on integrating the continuum of care for complex, frail, elderly, special needs, and dually-eligible individuals (Medicaid & Medicare). Organization looks to rebalance healthcare utilization from high cost undesirable institutional settings to lower cost home and community-based providers. Engagement was focused on reviewing operational processes associated with managed long term care line of business and providing data analysis and dashboarding to support business performance and quality reporting.
- Oversaw Phase II of claims payment initiative for Medicaid managed care insurer to address specific claims payment problem areas and identify operational best practices. Developed medical-operational policies / procedures, business rules and system configuration requirements used to adjudicate claims for accurate claim payment. Collaborated with client team and Third Party Administrator, including Operations, Medical Management, Provider Contracting, Finance, and IT to provide recommendations on business decisions to organization’s Senior Executives. Policies and recommendations addressed include the following areas: ambulance transportation services, laboratory tests, obstetrical services, and DRG-related and Ambulatory Surgical Center reimbursements.
- Oversaw development of payment accuracy center of excellence for national Medicaid managed care organization that included identification of $22.8M in potential savings related to operational improvements through payment accuracy related initiatives; defined new engagement operating model for enhancing collaboration between local and corporate operations and initiatives; and implemented critical tools to increase transparency of operations efficiencies across the enterprise.
Healthcare Reform / Health Insurance and Information Exchange
- Oversaw account team to establish a healthcare exchange program for large, multi-state Blues plan. Engaged by the CIO 2 years ago to revamp and oversee its $40 million public exchange mandates initiative that was continuously running over budget. Oversaw revamping of its program governance structure including leading its program management function, and delivering its four most complex projects (product development and rating, consumer direct enrollment and billing, small group quote to bill, and enrollment stabilization). Our team has successfully delivered these programs on time and on budget by providing transparency to client executive leadership and defining and implementing structure and rigor around program and project management capabilities.
- Led team and provided industry guidance and oversight to development of financial business model for state-wide Health Information Exchange (HIE) program. Work included identification of potential cost savings components associated with HIE implementation, collection of data and research across various healthcare populations, and determination of cost savings impact based on HIE functionality and provider adoption rate assumptions. Work also spanned numerous key stakeholder groups and required facilitation to support shared understanding and agreement of modeling assumptions.
- Developed proposal for major US metropolitan area health information exchange for providers across multiple care settings. Work included identification of critical challenges and risks associated with various information exchange models, governance arrangements, and operating models. Proposal addressed development of large-scale deployment approach, architecture solution, and workplan; and identification of opportunities for standardizing key aspects of solution alongside custom-required components of systems and processes given unique care setting needs.
Network Operations, Contracting, and Reimbursement
- Advised national behavioral services health plan on future state operating model for provider and network operations area to achieve over $20 million in savings. Achievement of results expected through recommended improvements to processes and technologies of management policies and procedures, workflow automation, and source data systems.
- Assessed claims accuracy issues for national healthcare insurance provider to determine impact on regional medical economics unit; work included evaluating magnitude of payment issues, determining root cause, and defining on-going process for assessing and addressing root cause for contracting and operational areas. Results included helping the plan redefine per member per month (PMPM) impact of payment inaccuracies from an original forecast of $0.87 PMPM to $3.39 PMPM.
- Engaged by national behavioral health service plans to assess provider and network operations areas and determine cost and operations improvement opportunities; led development of transition plan moving network operations from a shared service function to a service line-specific model, including development of a new organizational model, staff and role transition plans, and financial analysis modeling to reflect both impacted costs and savings of transition.
- Led implementation of a National Care Record Service for a mental health hospital in Northern England (400,000 patients), part of England’s National Health Service (NHS). Overall program focused on development of and connectivity to a centralized repository of patient health information accessible by health institutions across the country. Implementation was across major specialty areas including Forensic, Learning Disabilities, and Child Abuse and Mental Health Services and encompassed business process re-design, training, data migration, package configuration, legacy system integration, data warehousing, and testing/deployment.
Product Portfolio Strategy, Design, and Development
- Led product development initiative for national health plan to meet changing market needs and streamline product portfolios; developed product strategy for national health insurer to accelerate development of affordable, consumer-focused products within a 6-month timeframe. Detailed market research was performed and analyzed to establish critical product characteristics for particular market segments and to drive the evolution of key product portfolios in markets across the country.
- Served as Subject Matter Specialist for large regional health plan’s product development and rating workstream for healthcare exchanges. Identified strategies across all market segments, including individual, small group, as well as family/self segmentations. Worked with cross-functional teams to understand how product strategy for on and off exchanges impact operations across the enterprise, assessing and incorporating ACA legislative guidelines to strategy for compliance needs, and providing guidance on implementation of required changes to achieve reform timelines.
- Oversaw product consolidation strategy for regional Blues plan across multiple state markets to streamline product portfolio as approach for a $31 million migration of healthcare business onto single source-of-truth platforms, including consolidation of enrollment and billing information, build-out of provider networks, and conversion of data and business processes onto core claims platform.
Program Account / Management
- Led major international engagement for healthcare practice including 60-person team from five different countries with responsibilities for management of engagement economics, including forecasting, invoicing and managing of receivables across multiple countries, management of resources, including performance management practices, engagement policies and procedures and staffing.
- Developed uniform project management tools and processes as part of PMO for all transformation effort projects at multi-billion dollar healthcare insurance company to support consistent approaches and reporting practices. Directed work associated with group-based case installation and enrollment areas to define transformation projects and implementation of PMO processes and tools.
- Worked in PMO of leading global consumer products/retail company to monitor schedule and financial compliance status for Year 2000 projects of 122 global affiliates; analyzed performance trends of affiliates and identified areas requiring additional support including business partner assessment and contingency planning research; facilitated development of communications strategy for assisting affiliates communicate Year 2000 transition issues related to their business, community, and personnel.
Migration / Implementation
- Oversaw consolidation and migration planning of healthcare business across two state health plans, including consolidation of product port-folio, migration of Enrollment and Billing data onto a single platform (FACETS), build-out of provider networks, and the conversion of data and business processes onto a single claims platform.
- Planned and developed strategy for $250 million migration effort for national healthcare insurance carrier to migrate customer base of 40,000 groups (National Accounts, middle and small market groups, individual, premium and ASO business). Work included examination of impacts to all operational areas including sales, enrollment/eligibility, case installation, claims, servicing, billing, and financing, as membership migrated from multiple legacy environments (systems and processes) to new environments. Migration strategy addressed:
- Linkages and coordination points across functional areas when migrating populations
- Unique and similar characteristics of each membership population
- Required operational workarounds (manual and automated) necessary to ensure successful migrations
- Development of resource plan to support all migration activities during the 3 to 4 year period.