- Go-to-Market and Growth Strategies for PBMs and Health Plans
- PBM Procurement and Contract Management
- PBM Implementations
- Fraud, Waste and Abuse and Claims Accuracy Program Design
- PBM and Health Plan Organizational Assessments and Design
- 340b Program Design
- Part D Operations and Readiness Audits
Led the development of a five-year growth strategy with playbook for a Regional Managed Medicaid health plan to expand into nearby Medicaid regions, and to expand into Medicare Part D and commercial lines of business. This playbook provided, in the context of the Affordable Care Act, an overview of all expansion opportunities, varying strategic options, resource and investment needs, and operational impacts. The analysis included revenue projections based on demographic and estimated reimbursements, as well as scenario-based impact analyses based on variables such as membership growth (and decline) projections, premiums, and anticipated government reimbursements.
Analyzed and negotiated every form of PBM contract known in the industry for all lines of business, including Commercial, Medicaid, and Medicare. Working for both health plans and PBMs, he has unique insights into how PBM contracts are developed and negotiated from both sides. Mike's experience includes leading health plans through the PBM procurement process end-to-end: inclusive of business scope development, RFP creation, evaluation criteria, proposal assessment, negotiations, and contracting phases. In addition, Mike has negotiated contracts with health plans on behalf of PBMs.
- Health Plan Behavioral Program Strategy and Operations
- MBHO Program Design
- MBHO Procurement Management
- Health Plan Utilization Management and Case Management Strategy and Operations Design
- Medical Management Platform Assessments
- Medical Management Vendor Strategy and Operational Design
- Health Plan Portal and Mobile Program Design
- Pharmacy Engagement Tools and Strategy Development
- Agile Program Development
Core Administrative Operations:
- Operating Model Assessments and Design
- Enrollment, Billing and Claims Operations and Technology
- Network Operations
- Medicare Operations (Medical and Pharmacy)
- Health Plan and Vendor CMS Regulatory Assessments
- Vendor Integrations with Health Plans
Co-led the successful PBM transition and implementation for a large, national Blues plan of 5.1 million members, and approximately 230,000 claims adjudicated per day. In addition, Mike led operational implementation of three PBMs for a mid-sized regional Blues plan during the 2006 Medicare Part D rollout, resulting in close to 2 million members successfully enrolled.
Coordinated Part D client audits on behalf of a PBM focused on SAS-70 and NCQA delegated entity regulations, which spanned the entire operations of the organization. Worked with MA and PDP clients to prepare and participate in CMS audits, assisted with responses to CMS Corrective Action Plans (CAPs), developed management responses and oversaw the implementation of these CAPs. Provided guidance to clients regarding new CMS regulations issued via annual CMS Call Letters and memos.