Independent Healthcare Consultant specializing in Managed Care market expansion, strategic planning, payor and provider contracting, State License market feasibility and Certificate of Need (CON) Application assistance. I have assisted Health Maintenance Organizations, IPA's, Home Health Agencies, and Ambulatory Surgery Center clients over 10 years.

Identified ~$.5 million in financial leakage in network contracts. Analyzed network contracts; found 25% of contracts had loaded incorrectly rates; organized task force of provider network and third party claims administrator to review contracts and amend pricing with correct negotiated rates; established procedure to track and monitor implementation of new and existing contracts. Improved contract implementation controls; avoided tens of thousands of dollars in future unjustified payments.Led negotiations for Medicare Advantage Plan with dual demonstration program, Senior Care Options and Special Needs Plan (SNP). Recruited/Finalized provider contracts with providers*; developed renegotiation strategies; negotiated contract language and pricing to include fee for service, capitation and risk-share; coordinated contract execution/implementation; resolved network and contract issues; conducted meetings with key healthcare organizations, state representatives, opinion leaders and social service agencies to pave the way for future successful negotiations with major hospital facilities. Finalized 50+ provider contracts; completed 45 Letters of Agreement (LOAs).Established network development departmental policy and procedures (P&P) for Medicare Advantage Company. Researched Medicaid and Medicare regulations; reviewed existing systems and functions; interviewed key company representatives; authored P&P for i.e. provider access monitoring, timely access monitoring, health service delivery, non-emergency transportation, emergency medical care, second opinion, non-contracted provider; gained approval of executive leadership and compliance officer. Assured compliance with Medicaid and Medicare rules; company never cited for violations.

1995 - 1996, 2002 - 2007 (5years)Created network in metro Atlanta to meet Centers for Medicare & Medicaid Service (CMS) requirements for approval. Contacted by previous client, multispecialty IPA, to reintroduce managed care services; collaborated with IPA to select national Medicare advantage company with IPA serving as plan administrator; researched/approached hospitals, other IPAs, primary care, specialty and ancillary practice providers; ensured individual application submission met CMS requirements. Secured signing 1,256 providers and 7 hospital contracts; approval put on hold due to company’s sale to leading managed care provider. Solicited support, interest and potential referral agreements to satisfy “community linkage” requirement for State issuing Certificates of Need (CON) to home health agencies (HHA). Contacted/Set up meetings with stakeholder organizations, healthcare providers and business leaders in expansion regions including Chatham, Dougherty, Greene, Morgan, Oconee, and Oglethorpe counties; sent cover letter, marketing brochure “non-binding” Memorandum of Understanding made presentations on e.g. company overview, CON project information and HHA’s enhanced service offerings; obtained referral interest agreements (RIA’s). GA Department of Community Health, Healthcare Facility Regulation Division approved CON. Produced feasibility report for opioid treatment program (OTP) in GA. Conducted research; visited established OTP site in NC; interviewed CEO and program managers; developed survey questionnaire; concentrated on program description; market analysis; establishing referral system; proforma income and expense assumptions; physical plant characteristics; recommendations and comments and survey questionnaire visit findings. Report utilized for bank loan justification, pre-development activities such as start-up location, physical plant characteristics and establishment of a referral system; organization open OTP in GA.

Developed third party administrator (TPA) to administer self-insured program in GA. Completed feasibility work e.g. defining service, looking at market/competitors, determining budget, identifying business/staffing projections; developed org. charts and job descriptions; authored business plan; collected documents for submission to regulatory authorities; established relationships with reinsurance companies, PBMs, HMOs, PPOs, WC firms and brokers. TPA received licensure certification approval.Spearheaded review analysis of 500+ IPA Physician group to access and evaluate need for physician recruitment and adding new specialties panels in anticipation of future managed care business. Conducted competitive analysis to identify gaps in specialty offerings; examined requests by HMO/clients for services; compared to existing offerings; interviewed key opinion leaders; developed report to present to IPA Board. Increased group size by 20% through provider recruitment. Designed reconciliation strategy at request of CEO to resolve outstanding claims following termination of risk arrangements with major HMO companies. Directed members of team to meet with network physician practices to discuss/resolve outstanding claims issues; met with key providers; explained hardship in meeting current obligations; requested groups suffer immediate losses (write-offs) in hopes of stronger business collaborations in future. Saved organization $.5 million; left organization in better financial condition.

Served as lead contract negotiator for Saint Joseph’s Hospital’s health care insurance services via managed care plan federally funded by Medicare. Developed ancillary network; recruited targeted primary care and specialty medical groups in 5 metro counties; finalized addendum agreements to add services to existing agreements managed all aspects of contracts through execution; assisted in preparing for CMS’s regulatory site visit; worked collaborative with claims, member services, IT, enrollment, credentialing etc. to resolve issues; negotiated out of network “Letters of Agreement.” Executed 75+ ancillary contracts, 50 primary care and specialty care contracts; completed 90 Letters of Agreement (LOA’s).

Coordinated statewide research study looking at Georgia citizen’s values in healthcare to be used to determine Public Policy in State.