LD Health, LLC
- Developed the Savings Model for Phase 2 Maryland Waiver negotiations with CMMI; Medicare Cost projections for MD and US to 2023
- Developed the financial model for the Maryland Primary Care Model program with cost and savings projections for MD to 2023
- Created reporting and analytics through queries on the CMS Chronic Condition Warehouse for the HSCRC for trends in cost, utilization, global budget leakage, waiver performance, etc.
- Presented Medicare claims analyses based on CMMI reporting to HSCRC Commissioners during monthly, closed session, commission meetings
- Prepared and reviewed HSCRC vendor and CMMI reporting on Medicare hospital and Total Cost of Care performance in MD versus National trends; Reviewed Lag factors and Savings calculations for tracking towards Waiver performance
- Worked with the HSCRC vendors on the design and reporting of facility-level referral patterns between Acute Hospital and post-acute facilities out of the Chronic Condition Warehouse
- Performed risk adjustment score development (HCC, CDPS, ACG and CRG models) on MD patients using HSCRC case-mix data and CRISP’s Master Patient Identifie (MPI); Created various other reporting out of the HSCRC case-mix data including counts of admissions, ED visits, Charges and calculation of LACE index scores for likelihood of hospital re-admission using CRISP’s Master Patient Identifier (MPI); Authored white paper for CRISP’s Integrated Care Network development on risk stratification model results, conclusions and recommendations
- Engaged with CRISP on the acquisition of identifiable Medicare Claims and Assessment data for the State of Maryland
- Continued analysis of Medicare Advantage claims and Revenue for a Medicare Advantage client
- Experienced user/programmer in SAS, SQL, MS Office and Visual Basic for Applications within Office for more efficient workflow development and creation of business intelligence tools
CIGNA-Healthspring
- Vice-President with focus on clinical and financial analysis and reporting for Medicare Advantage and Medicaid managed care
- Led development of databases that provide all Medicare cost trending by market, including segmentation by provider types and member sub-populations; Created reference tables for Medicare FFS pricing methodologies including IPPS, OPPS, RUGs (SNF), HIPPS (Home Health), and Physician RVUs and ancillary professional fee schedules; Created tables and reporting for benchmarking against Medicare FFS using the CMS provider utilization files
- Developed cost adjustment factors, HCC risk factors and reports that are used for Medicare Advantage bids and CMS rate setting process
- Developed and performed revenue and cost modeling, analyzed impact of Medicare reimbursement and regulatory changes, and performed other complex modeling activities relative to Medicare segment
- Led claims analysis and reporting, cost containment, risk adjustment and segmentation, and provider payment and incentives operations and analysis
- Conceived, designed, and implemented sophisticated claims and cost analysis reporting.
- Led a Medical Economics team for Maryland and Pennsylvania
- Extensive work with HSCRC hospital reimbursement and reporting including experience reports, case-mix weight reports, GME Discounts and hospital inpatient and outpatient encounter data maintained by HSCRC
- Worked with CRISP in providing member and demographic data, using ENS notifications, and in providing input into the development and use of CRISP’s payer portal
- Annual HIPAA training
Express Scripts, Inc. (ESI)
- Senior Business Manager for one of the largest Pharmacy Benefits Management (PBM) in the world
- Extensive experience in working with pharmacy claims, Medicare Part D and their elements (NDC, GCN, GPI, AWP, ASP, WAC, MAC, ingredient cost, dispensing fees, etc.)
- Conceived and designed the complex generic drug pricing algorithm for ESI, which manages the relationships among hundreds of generic drug pricing lists (MAC) and sets hundreds of thousands of price points under millions of criteria in an automated linear programming model
- Assisted in the design of underwriting and contract valuations with retail pharmacy networks
LD Consulting 