Michael Wolfman Email & Phone Number

Schaumburg, Il

Managed overall financial accountability of pharmacy audits, including contractual compliance, plan design, and pricing exceptions for customers of various sizes including large managed care organization, government agencies, multi-employer coalitions and union funds. Consulted clients on financial aspects of their contract and impact the contract has on overall pharmacy costs including the identification of industry “games”.•Developed Access-based analytical tools that tracked contractual and/or infractions with prescription drug regulations including Fraud Waste and Abuse. Process included reporting/dashboard reports for plan sponsors to pinpoint specific areas of concern including narcotic abuse, invalid prescriptions and collusion between physicians, pharmacies and members. •Audited statistical data to identify and report all aspects of pricing including pricing integrity, discounts that are applied, dispensing fees, U&C Pricing, administration fees and Maximum Allowable Cost pricing. Realized savings/penalties up to $300,000 per analysis.•Audited plan design including co-pays, exclusions, formulary compliance, prior authorization, quantity limits, “refills too soon” and duplicate claims. Analyzed eligibility files to determine if claims were paid for members who are no longer eligible.•Audited Medicare claims focusing on items such as True Out of Pocket expense (TrOOP) calculations, benefit levels, Low Income Subsidy claims and co-pays, Medicare Part B vs. Part D drugs, and PDE records/calculations including Covered Plan Paid Amounts(CPP) and Non-Covered Plan Paid Amounts(NPP).•Analyzed pricing proposal (Request For Proposal) information to ensure that the objectives and services of the plan(s) are met by the new/existing PBM, pricing terms reflect market conditions by re-pricing claims. Enhanced process to apply overall governance to the PBM bids comparison. Results showed potential savings up to $2.8 million.

Analyzed the impact of medical claim history, utilization patterns, and plan design changes on plan performance for 20-30 Fortune 500 companies. Prepared and delivered comprehensive reporting packages, providing insight into the cause and impact of key expense drivers on claim experience and trends. Reported directly to the Regional Underwriting Director.•Developed strategies that lowered employer and employee medical costs.•Analyzed and evaluated claim data against past history and industry standards. •Customized ad hoc reports that met the expectations of internal and external customers. •Contributed to a 96% client retention rate by delivering exemplary customer service.

Prepared $79 million regional operating and capital expenditure budget encompassing five (5) offices and 1200 employees. Prepared, documented, and presented monthly, quarterly, and year-end budget variance and expense forecasts to senior management. Monitored capital expenditures. Developed reporting packages and ad hoc reports, monitored performance guarantees, and estimated financial impact. •Recommended business improvements that significantly reduced expenses while improving operational efficiency.•Improved accuracy and timeliness of responding to Dept. of Insurance inquiries and executive complaints by automating monthly compliance reporting procedures.•Facilitated placement of new business within the capacity of the claim and service centers.•Eliminated negative impact of office restructuring by applying capacity forecasting and modeling to realign customer claim and service call routing.