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Accredited Health Care Fraud Investigator with over 35 years of Medicare experience with 30 devoted to health care FWA investigations, as well as commercial health insurance. Extensive knowledge in the interpretation/application of program policies: regulations, NDCs, and LCDs to apply the provisions of the Social Security Act and their significance in the identification, prevention and investigation of FWA. Trained and knowledgeable in all dimensions of FWA detection/investigations: audit and quality assurance control, documentation, application of coding/pricing standards, compliance with Federal statutory and regulatory requirements, medical terminology, and adherence to HIPAA. Wide-ranging Medicare and Medicaid investigative experience including data analysis to identify potential claim/encounter billing abnormalities, medical record documentation reviews, on-site inspections, in-person/telephonic interviews, overpayment statistical projection sampling and recoveries, referrals to law enforcement, prepayment reviews, payment suspensions, preparation of potential Fraud Alerts/Program Vulnerabilities, as well as referrals to Physician Boards for quality of care. Power-user of STARSInformant analytic tool to perform in-depth data analysis to identify and investigate patterns of Medicare and Medicaid FWA claim billings. Senior Lead Trainer and Senior Advisor of STARSInformant to government users on the CMS Integrated Data Repository’s One Program Integrity Portal since 2012. Power-user of STARSSentinel to identify potential FWA leads as a starting point for initiating potential cases, demanding overpayments, creating provider educational programs or recommending claims editing improvements. In-depth experience managing a Special Investigation Unit. Professional presenter of summary and claim line data uncovering fraudulent pattens indicative of fraud on numerous occasions since 2011 to the CMS’ CPI and the Veterans Affairs. Professional presenter of health care fraud cases to various law enforcement agencies including the DOJ, OIG, and FBI.
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One Program Integrity Data Coach For Optum ServeGeneral Dynamics Information Technology Jul 2018 - PresentWindsor Mill, Md (Remote From Timonium, Md)Provide Medicare and Medicaid health care claims knowledge, data analytics, and fraud investigative expertise to One Program Integrity STARSInformant and BusinessObjects government users. Create data enhancements and application interface changes for continuous improved user experience. Create and prioritize Agile Program Increment enhancements for One Program Integrity users. Train virtual STARSInformant beginner and advanced classes. Attend and provide SME during onsite and customer site training classes. Presenter of data and tool enhancements, as well as analytic tool functionalities at Program Integrity Data Utilization Group (PIDUG) meetings. SME fo the STARSInformant Level 3 Technical team. Quality Analyst of enhancements during implementation in the lower environments. Cloud regression tester to verify application functions work or changes created bugs for route cause analysis and resolution by the vendor. -
Sr. Lead Trainer, Medicare Subject Matter Expect/Sr. Advisor, Functional AnalystGeneral Dynamics Information Technology May 2012 - PresentUnited States•Analyzes user (CMS, DOJ, MAC, MEDIC, OIG, PSC, RRB, ZPIC) needs and performs functional analysis on Medicare claim and ancillary data including the interpretation of Medicare codes, health care laws, regulations, and policies.•Develops and delivers moderately complex user educational training programs of the STARSInformant application utilizing Medicare claim and ancillary data to combat health care fraud, waste, and abuse (FWA). •Provides data coaching for complex user requests. •Uses knowledge of health care coding conventions, fraud schemes, areas of vulnerability, reimbursement methodologies, and relevant laws to assist users in identifying suspicious patterns in claims, pharmacy records, provider enrollment data, and other sources as requested and identified during analysis and assistance. •Develops and delivers webinars to provide education of release enhancements, tips to efficiently use STARSInformant on the IDR, and instructions on advanced functions. •Applies business intelligence and user functionality requirements in the ongoing development of the application's future releases.•Participates in Change Advisory Board meetings to discuss enhancements, business requirements and release schedule prioritization. •Serves as Subject Matter Expert for less-experienced business/technical analysts on the application's functions and health care FWA. •Executes lower environment regression testing and final approval sign-off for deployment of new code to the Production environment.•Performs integration mapping structure of the STARSInformant application for the National Claims History File and Medicare’s Claims Processing Shared Systems (FISS, MCS, and VMS). •Initiates enhancement requests with business cases for improved user graphical interface and report data output. •Maintains current knowledge of emerging FWA scenarios. •Creates and updates documentation including procedures, presentations, and training materials
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Fraud & Abuse Product/Fraud Services SpecialistGeneral Dynamics Information Technology Jan 2009 - May 2012United States•Conducted independent investigations to identify potential FWA for commercial health payers. •Prepared case referrals thoroughly documenting all investigative actions substantiating fraudulent billings.•Analyzed customers’ claims data utilizing STARSSentinel, STARS rebranded to STARSInformant, and Microsoft Excel to identify and develop fraud scheme leads and/or overpayments.•Interviewed providers and insurers to substantiate unethical or improper claim billings. •Supported the development of the STARSSentinel application’s statistical algorithms to create new sophisticated rules-based logic and modify existing rules to keep current with emerging fraudulent schemes with business intelligence, as well as user functionality requirements on an ongoing basis. •Used knowledge of health care coding conventions, fraud schemes, and general areas of vulnerability, reimbursement methodologies, and relevant laws to find suspicious patterns in claims data, provider enrollment data, and other external sources. •Demonstrated STARS to the U.S. Attorneys from the DOJ focusing on how the application could better integrate into their FWA detection efforts translating multiple actual data leads into health care fraud business cases. •Conducted additional data analysis using STARS to identify FWA leads for the DOJ in several high risks areas. •Performed all responsibilities as directed by various customers.
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Accredited Health Care Fraud InvestigatorNational Health Care Anti-Fraud Association May 2011 - PresentUnited States -
Sales RepresentativeJones & Jones, Inc. Jun 2008 - Sep 2009United States•Reconciled merchandise in high-end women's boutique. •Priced merchandise and prepared for showroom display. •Recommended merchandise appropriate to clientele's clothing or accessory style. •Handled in-store and out-of-state sales transactions. •Rearranged the display of seasonal merchandise. •Ordered merchandise as needed per clientele request.•Opened and closed the boutique as needed.
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Benefit Integrity Site Lead ManagerTricenturion, Llc Aug 2002 - May 2008Columbia, South Carolina Area•Hired, trained and managed a SIU team of 18 in all activities related to Medicare FWA for the site’s region that included MD, DE, VA, and the District of Columbia. •Supervised the direction of over 4,000 investigations and as a result of case referrals to OIG, resulting in the recovery of over $31M for the Medicare program.•Oversaw responsibilities of subordinate employees to achieve corporate business goals aligning individual goals to also meet the requirements of the government’s Statement of Work (SOW). •Applied strategic planning, prioritization, and project management skills toward consistently achieving critical deadlines while maintaining high quality standards.•Reviewed the progress of all investigations on a monthly basis to ensure compliance with all aspects of the CMS’ PI manual, health care laws, regulations and policies.•Provided guidance and assistance to subordinate employees in the development of investigations to ensure compliance of the OIG’s case referral expectations. •Approved subordinate employee recommended implementation and/or revision of Medicare program and policy changes when inefficiencies or vulnerabilities were identified during the investigation process including Fraud Alert and Program Vulnerabilities. •Directed investigative teams to achieve on-site audit expectations in documentation collection and chain-of-custody reports. •Acted as liaison to foster successful partnerships with CMS, DOJ, OIG and other agencies during the prosecution of health care fraud cases including the recovery of statistical overpayment recoveries. . •Developed and maintained effective relationships with affiliated MACs to expedite the handling of Requests for Information (RFIs) from law enforcement. •Referred providers to the Maryland Board of Physicians for exclusion consideration when patient harm was identified including testimony on the basis of case referrals.
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Fraud SpecialistVips Mar 2002 - Jul 2002United States•Assisted and provided guidance to the sub-contractor's investigative staff including the interpretation and application of health care laws, regulations and policies. •Participated in government request for proposals. •Analyzed, tested, and recommended enhancements to the STARS application. -
Benefit Integrity ManagerTrailblazer Health Enterprises, Llc Jan 2000 - Feb 2002United States•Hired, trained, and managed a SIU team of 9 in all activities related to Medicare FWA for a region that included two states. •Oversaw all responsibilities of staff to achieve corporate business goals aligning individual goals with the requirements of the government’s SOW/TO. •Reviewed the progress of all investigations on a monthly basis to ensure compliance with aspects of the CMS’ PI manual, health care laws, regulations and policies. •Provided guidance and assistance to staff in the development of investigations to ensure compliance of the OIG’s case referral expectations. •Fostered a partnership with CMS, DOJ, OIG and other agencies during the prosecution of health care fraud cases including the recovery of overpayments. •Developed and maintained effective relationships with affiliated MACs to expedite the handling of RFIs from law enforcement. •Conducted quality assurance of workload to meet the CMS’ contractor performance evaluation inspections. •Developed and maintained effective relationships with members of the management team, staff and external customers. •Professional speaker at the Denver, CO NHCAA Benefit Integrity Conference concerning the civil monetary penalty remedy the CMS may pursue on cases declined for prosecution.
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Fraud InvestigatorTrailblazer Health Enterprises, Llc Jan 1992 - Dec 1999United States•Performed in-depth analysis of Medicare claims to identify provider billing patterns indicative of FWA. •Investigated and prepared case referrals for consideration of prosecution by law enforcement. •Interpreted and applied health care laws, regulations and policies to abide by the Medicare program. •Conducted over 90 investigations with 100% case acceptance by OIG due to thoroughness of the referral as outlined in the CMS’ PI manual. •Interviewed providers and beneficiaries to substantiate unethical or improper claim billings.•Reviewed medical record documentation for medical necessity and appropriateness of code billings. •Responded to RFIs from law enforcement. •Validated providers and/or FWA scenarios in the Fraud Investigative Database (FID).•Documented all activities of substantiated investigations and cases in the FID until administrative closure, prosecution and/or settlement. •Initiated prepayment review and recommended payment suspension to protect the Medicare Trust fund. •Recommended the implementation and/or revision of Medicare program and policy changes when inefficiencies or vulnerabilities were identified during the investigation process. •Participated in the post-payment review of claims to identify and recover overpaid claims.
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Fraud SpecialistTrailblazer Health Enterprises, Llc Jan 1991 - Dec 1991United States•Researched and responded to inquires of adjudicated claims.•Educated beneficiaries on the Medicare program through outreach seminars. •Audited correspondence files for quality assurance.
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Customer Service RepresentativeBlue Cross & Blue Shield Of Maryland Jan 1986 - Dec 1990United States•Researched and responded to allegations of fraud.•Interpreted and applied health care laws, regulations, and policies to abide by the Medicare program. •Responded to RFIs from law enforcement. •Educated providers in proper claim submissions.•Maintained a case control and accountability system of all allegations.
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Claims ExaminerBlue Cross & Blue Shield Of Maryland Oct 1984 - Dec 1985United States•Analyzed Medicare policy and regulations. •Determined appropriate adjudication of Medicare claims.
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Frequently Asked Questions about Barbara Connolly
What company does Barbara Connolly work for?
Barbara Connolly works for General Dynamics Information Technology
What is Barbara Connolly's role at the current company?
Barbara Connolly's current role is One Program Integrity Data Coach.
What is Barbara Connolly's email address?
Barbara Connolly's email address is ba****@****dit.com
What skills is Barbara Connolly known for?
Barbara Connolly has skills like Data Analysis, Training Classroom And Onsite At Customer Location, Public Speaking, Health Care Fraud Investigations, One On One Data Coaching, Implementing Software Application Changes.
Who are Barbara Connolly's colleagues?
Barbara Connolly's colleagues are Beth Maedge, Abu Said Rahi, Aaron Possis, Santiago Perez, Jennifer Jones, Shaquana Hall, Popi Aktar.
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Barbara Connolly
Morton Grove, Il6servicemaster.com, aol.com, servicemaster.com, aol.com, comcast.net, idexcorp.com1 (847) 4XXXXXXX
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