Agenda Links: Preconference | Day 3
AGENDA: DAY 2
TUESDAY, JULY 30, 2019
7:00 am
Registration Opens
MORNING PLENARY SESSION
8:00 am
Welcome, Audience Response, and Outline of the Boot Camp
Day Egusquiza
President and Founder, AR Systems, Inc. and Patient Financial Navigator Foundation, Inc., Twin Falls, ID
President and Founder, AR Systems, Inc. and Patient Financial Navigator Foundation, Inc., Twin Falls, ID
Day Egusquiza brings over 40 years experience in health care reimbursement, hospital business office operations (20 years in an Idaho hospital), contracting, auditing and compliance implementation. Additionally, her experience includes eight years as a Director of a Physician Medical Management billing service which included completing an integrated business office between a hospital and a large multi-specialty physician clinic. She has been an entrepreneur in hospital and physician practice accounts receivable management and a leader in redesigning numerous organizations. Her work includes providing guidance as a compliance & reimbursement educator while providing operational insight on the revenue cycle impacts of disruption, lost charges, coding validation and yes, why I love Traditional Medicare’s 2 MN rule. Day’s strength is her ability to ‘operationalize’ complex regulations into teachable components.
Ms Egusquiza is a nationally recognized speaker on continuous quality improvement (CQI), benchmarking, redesigning, reimbursement systems and implementing an operational focus of compliance- both in hospitals and practices. She has been on the AAHAM National Advisory Council, HFMA National Advisory Council, is a past President of the Idaho HFMA Chapter & recently received the Lifetime Achievement Award. She has been highlighted in JCAHO’s Six Hospitals in Search of Excellence, Zimmerman’s Receivable Report, HFMA’s HFM and Patient Account, AHIA Prospective, and numerous healthcare newsletters along with a contributing author to 2006 Health Law and Compliance Update. She received the Idaho Hospital Association “Distinguished Service Award” for her legislative work and training on new indigent law. Attendees at HFMA’s ANI rated her in the top 25% for each year she has presented, earning her the ‘Distinguished Speaker’ award.
Her greatest accomplishments are her four wonderful children and her eight fabulous grandchildren.
What makes her unique? She has been in the trenches with us!
Points of Interest:
Ms Egusquiza is a nationally recognized speaker on continuous quality improvement (CQI), benchmarking, redesigning, reimbursement systems and implementing an operational focus of compliance- both in hospitals and practices. She has been on the AAHAM National Advisory Council, HFMA National Advisory Council, is a past President of the Idaho HFMA Chapter & recently received the Lifetime Achievement Award. She has been highlighted in JCAHO’s Six Hospitals in Search of Excellence, Zimmerman’s Receivable Report, HFMA’s HFM and Patient Account, AHIA Prospective, and numerous healthcare newsletters along with a contributing author to 2006 Health Law and Compliance Update. She received the Idaho Hospital Association “Distinguished Service Award” for her legislative work and training on new indigent law. Attendees at HFMA’s ANI rated her in the top 25% for each year she has presented, earning her the ‘Distinguished Speaker’ award.
Her greatest accomplishments are her four wonderful children and her eight fabulous grandchildren.
What makes her unique? She has been in the trenches with us!
Points of Interest:
- AICPA: Planning Committee member for healthcare, Chair 2004-2011
Speaker at 14 annual conferences, board member 8 years
- AHIA: National conference key note speaker
- HFMA: National faculty member; presenter at ANI; national revenue cycle conference; two-day cluster; CFO Forums; regional conferences with continual evaluations in the top 25% -earning the Distinguished Speaker Award yearly.
- Instructor: College of Southern Idaho, continuing education program on “Understanding the Medicare Benefit.”
- Board of Directors: Special Olympics of Idaho,2003-2007. Secretary 2004
- Contributing Editor; AAHAM Technical Certification Study Guide, revised March 2004; CPAT & CCAT exams
- Co-Chair of national RAC Summit (2009-current)
- Co-Creator of the national Physician Advisor and UR Boot camp (2012-current)
- President and Founder of the Patient Financial Navigator Foundation, Inc, – a Idaho-based family foundation- transforming the hassle factor in healthcare thru education.
8:45 am
What Does Disruption in Healthcare Look Like?
Day Egusquiza
President and Founder, AR Systems, Inc. and Patient Financial Navigator Foundation, Inc., Twin Falls, ID
President and Founder, AR Systems, Inc. and Patient Financial Navigator Foundation, Inc., Twin Falls, ID
Day Egusquiza brings over 40 years experience in health care reimbursement, hospital business office operations (20 years in an Idaho hospital), contracting, auditing and compliance implementation. Additionally, her experience includes eight years as a Director of a Physician Medical Management billing service which included completing an integrated business office between a hospital and a large multi-specialty physician clinic. She has been an entrepreneur in hospital and physician practice accounts receivable management and a leader in redesigning numerous organizations. Her work includes providing guidance as a compliance & reimbursement educator while providing operational insight on the revenue cycle impacts of disruption, lost charges, coding validation and yes, why I love Traditional Medicare’s 2 MN rule. Day’s strength is her ability to ‘operationalize’ complex regulations into teachable components.
Ms Egusquiza is a nationally recognized speaker on continuous quality improvement (CQI), benchmarking, redesigning, reimbursement systems and implementing an operational focus of compliance- both in hospitals and practices. She has been on the AAHAM National Advisory Council, HFMA National Advisory Council, is a past President of the Idaho HFMA Chapter & recently received the Lifetime Achievement Award. She has been highlighted in JCAHO’s Six Hospitals in Search of Excellence, Zimmerman’s Receivable Report, HFMA’s HFM and Patient Account, AHIA Prospective, and numerous healthcare newsletters along with a contributing author to 2006 Health Law and Compliance Update. She received the Idaho Hospital Association “Distinguished Service Award” for her legislative work and training on new indigent law. Attendees at HFMA’s ANI rated her in the top 25% for each year she has presented, earning her the ‘Distinguished Speaker’ award.
Her greatest accomplishments are her four wonderful children and her eight fabulous grandchildren.
What makes her unique? She has been in the trenches with us!
Points of Interest:
Ms Egusquiza is a nationally recognized speaker on continuous quality improvement (CQI), benchmarking, redesigning, reimbursement systems and implementing an operational focus of compliance- both in hospitals and practices. She has been on the AAHAM National Advisory Council, HFMA National Advisory Council, is a past President of the Idaho HFMA Chapter & recently received the Lifetime Achievement Award. She has been highlighted in JCAHO’s Six Hospitals in Search of Excellence, Zimmerman’s Receivable Report, HFMA’s HFM and Patient Account, AHIA Prospective, and numerous healthcare newsletters along with a contributing author to 2006 Health Law and Compliance Update. She received the Idaho Hospital Association “Distinguished Service Award” for her legislative work and training on new indigent law. Attendees at HFMA’s ANI rated her in the top 25% for each year she has presented, earning her the ‘Distinguished Speaker’ award.
Her greatest accomplishments are her four wonderful children and her eight fabulous grandchildren.
What makes her unique? She has been in the trenches with us!
Points of Interest:
- AICPA: Planning Committee member for healthcare, Chair 2004-2011
Speaker at 14 annual conferences, board member 8 years
- AHIA: National conference key note speaker
- HFMA: National faculty member; presenter at ANI; national revenue cycle conference; two-day cluster; CFO Forums; regional conferences with continual evaluations in the top 25% -earning the Distinguished Speaker Award yearly.
- Instructor: College of Southern Idaho, continuing education program on “Understanding the Medicare Benefit.”
- Board of Directors: Special Olympics of Idaho,2003-2007. Secretary 2004
- Contributing Editor; AAHAM Technical Certification Study Guide, revised March 2004; CPAT & CCAT exams
- Co-Chair of national RAC Summit (2009-current)
- Co-Creator of the national Physician Advisor and UR Boot camp (2012-current)
- President and Founder of the Patient Financial Navigator Foundation, Inc, – a Idaho-based family foundation- transforming the hassle factor in healthcare thru education.
9:40 am
Regulatory Updates
Ronald Hirsch, MD, FACP, CHCQM, CHRI
Vice President, Regulations and Education Group, R1 RCM Inc., Chicago, IL
Vice President, Regulations and Education Group, R1 RCM Inc., Chicago, IL
Dr. Ronald Hirsch is a Vice President of the Regulations and Education Group at R1 RCM Inc.
Dr. Hirsch was a general internist and HIV specialist and practiced at Signature Medical Associates, a multispecialty practice located in Elgin, IL. He was Medical Director of Case Management at Sherman Hospital in Elgin, IL from 2006 to 2012, where he was Chairman of the Medical Records Committee from 1995 to 2012, and also served on the Medical Executive Committee.
Dr. Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, certified in Revenue Integrity by the National Association of Healthcare Revenue Integrity, and on the Advisory Board of the American College of Physician Advisors. He is on the editorial board of RACmonitor.com. He is the co-author of The Hospital Guide to Contemporary Utilization Review, with the second edition published in 2018
Dr. Hirsch was a general internist and HIV specialist and practiced at Signature Medical Associates, a multispecialty practice located in Elgin, IL. He was Medical Director of Case Management at Sherman Hospital in Elgin, IL from 2006 to 2012, where he was Chairman of the Medical Records Committee from 1995 to 2012, and also served on the Medical Executive Committee.
Dr. Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, certified in Revenue Integrity by the National Association of Healthcare Revenue Integrity, and on the Advisory Board of the American College of Physician Advisors. He is on the editorial board of RACmonitor.com. He is the co-author of The Hospital Guide to Contemporary Utilization Review, with the second edition published in 2018
10:25 am
Break
MEDICARE ADVANTAGE OVERVIEW
10:50 am
All Things MA
David Ault
Counsel, Faegre Baker Daniels, LLP, Former Director at HHS of the Division of Financial Risk in the CMMI and litigator in the CMS Division of the HHS Office of General Counsel, Washington, DC
Counsel, Faegre Baker Daniels, LLP, Former Director at HHS of the Division of Financial Risk in the CMMI and litigator in the CMS Division of the HHS Office of General Counsel, Washington, DC
Drawing from his background in leadership positions with the U.S. Department of Health and Human Services (HHS), David Ault advises health care providers and payers on the regulatory, compliance and litigation aspects of health insurance. Prior to joining Faegre Baker Daniels, Dave served in HHS as director of the Division of Financial Risk in the Center for Medicare and Medicaid Innovation (CMMI) and, before that, as a litigator in the Centers for Medicare and Medicaid Services (CMS) Division of the HHS Office of General Counsel. His recent CMMI work involved leading several advanced payment model initiatives at the core of moving Medicare from fee-for-service to value-based strategies, including CMMI’s accountable care organization models, Medicare Advantage models, and Medicare Part D models.
11:30 am
Understanding Audit Risk Adjustments, Provider Networks, and CMS’s Oversight Responsibilities
Mike Adelberg
Principal, Faegre Baker Daniels Consulting; Former Director of Medicare Advantage Operations and Former Acting Director of Exchange Policy and Operations, CMS, Washington, DC
Principal, Faegre Baker Daniels Consulting; Former Director of Medicare Advantage Operations and Former Acting Director of Exchange Policy and Operations, CMS, Washington, DC
Mike Adelberg leads the Healthcare Strategy Practice at Faegre Baker Daniels Consulting. He has 25 years progressive healthcare industry and government experience in Medicare, Medicaid and commercial health insurance. Mike spent fifteen years at the Centers for Medicare and Medicaid Services (CMS), including concurrently serving as the director of the Insurance Programs Group and the acting director of the Exchange Policy and Operations Group in the Center for Consumer Information and Insurance Oversight (CCIIO) where he oversaw most of the functions of the federally-run health insurance exchanges; serving as the Director of Medicare Advantage Operations, where he supervised the annual cycle for review and award of Medicare Advantage bids and contracts and led the monitoring of Medicare Advantage contractors; and serving as the associate regional administrator for Medicare operations (Chicago Region) and the director of education and assistance programs. Mike gained private sector experience as vice president of product development and government affairs for the Universal American Corporation, a multi-state health insurer which operated Medicare Advantage and Medicaid health plans (subsequently acquired by Wellcare). He has also led or co-led health policy studies published in Health Affairs and The American Journal of Managed Care. Mike speaks and publishes frequently on healthcare topics and has served on numerous advisory committees. He’s been quoted in the Washington Post, New York Times, Modern Healthcare, NPR, and other leading media. In his spare time, Mike is an author. He’s written three novels, a history book, several scholarly journal articles, and over sixty book reviews.
12:05 pm
Morning Faculty Q&A Panel
12:25 pm
Working Lunch – Networking Tables & Case Studies
1:50 pm
Presentation of Case Studies
2:20 pm
Managed Care Anguish
Day Egusquiza
President and Founder, AR Systems, Inc. and Patient Financial Navigator Foundation, Inc., Twin Falls, ID
President and Founder, AR Systems, Inc. and Patient Financial Navigator Foundation, Inc., Twin Falls, ID
Day Egusquiza brings over 40 years experience in health care reimbursement, hospital business office operations (20 years in an Idaho hospital), contracting, auditing and compliance implementation. Additionally, her experience includes eight years as a Director of a Physician Medical Management billing service which included completing an integrated business office between a hospital and a large multi-specialty physician clinic. She has been an entrepreneur in hospital and physician practice accounts receivable management and a leader in redesigning numerous organizations. Her work includes providing guidance as a compliance & reimbursement educator while providing operational insight on the revenue cycle impacts of disruption, lost charges, coding validation and yes, why I love Traditional Medicare’s 2 MN rule. Day’s strength is her ability to ‘operationalize’ complex regulations into teachable components.
Ms Egusquiza is a nationally recognized speaker on continuous quality improvement (CQI), benchmarking, redesigning, reimbursement systems and implementing an operational focus of compliance- both in hospitals and practices. She has been on the AAHAM National Advisory Council, HFMA National Advisory Council, is a past President of the Idaho HFMA Chapter & recently received the Lifetime Achievement Award. She has been highlighted in JCAHO’s Six Hospitals in Search of Excellence, Zimmerman’s Receivable Report, HFMA’s HFM and Patient Account, AHIA Prospective, and numerous healthcare newsletters along with a contributing author to 2006 Health Law and Compliance Update. She received the Idaho Hospital Association “Distinguished Service Award” for her legislative work and training on new indigent law. Attendees at HFMA’s ANI rated her in the top 25% for each year she has presented, earning her the ‘Distinguished Speaker’ award.
Her greatest accomplishments are her four wonderful children and her eight fabulous grandchildren.
What makes her unique? She has been in the trenches with us!
Points of Interest:
Ms Egusquiza is a nationally recognized speaker on continuous quality improvement (CQI), benchmarking, redesigning, reimbursement systems and implementing an operational focus of compliance- both in hospitals and practices. She has been on the AAHAM National Advisory Council, HFMA National Advisory Council, is a past President of the Idaho HFMA Chapter & recently received the Lifetime Achievement Award. She has been highlighted in JCAHO’s Six Hospitals in Search of Excellence, Zimmerman’s Receivable Report, HFMA’s HFM and Patient Account, AHIA Prospective, and numerous healthcare newsletters along with a contributing author to 2006 Health Law and Compliance Update. She received the Idaho Hospital Association “Distinguished Service Award” for her legislative work and training on new indigent law. Attendees at HFMA’s ANI rated her in the top 25% for each year she has presented, earning her the ‘Distinguished Speaker’ award.
Her greatest accomplishments are her four wonderful children and her eight fabulous grandchildren.
What makes her unique? She has been in the trenches with us!
Points of Interest:
- AICPA: Planning Committee member for healthcare, Chair 2004-2011
Speaker at 14 annual conferences, board member 8 years
- AHIA: National conference key note speaker
- HFMA: National faculty member; presenter at ANI; national revenue cycle conference; two-day cluster; CFO Forums; regional conferences with continual evaluations in the top 25% -earning the Distinguished Speaker Award yearly.
- Instructor: College of Southern Idaho, continuing education program on “Understanding the Medicare Benefit.”
- Board of Directors: Special Olympics of Idaho,2003-2007. Secretary 2004
- Contributing Editor; AAHAM Technical Certification Study Guide, revised March 2004; CPAT & CCAT exams
- Co-Chair of national RAC Summit (2009-current)
- Co-Creator of the national Physician Advisor and UR Boot camp (2012-current)
- President and Founder of the Patient Financial Navigator Foundation, Inc, – a Idaho-based family foundation- transforming the hassle factor in healthcare thru education.
2:50 pm
Medicare Advantage – a Patient Perspective
Day Egusquiza
President and Founder, AR Systems, Inc. and Patient Financial Navigator Foundation, Inc., Twin Falls, ID
President and Founder, AR Systems, Inc. and Patient Financial Navigator Foundation, Inc., Twin Falls, ID
Day Egusquiza brings over 40 years experience in health care reimbursement, hospital business office operations (20 years in an Idaho hospital), contracting, auditing and compliance implementation. Additionally, her experience includes eight years as a Director of a Physician Medical Management billing service which included completing an integrated business office between a hospital and a large multi-specialty physician clinic. She has been an entrepreneur in hospital and physician practice accounts receivable management and a leader in redesigning numerous organizations. Her work includes providing guidance as a compliance & reimbursement educator while providing operational insight on the revenue cycle impacts of disruption, lost charges, coding validation and yes, why I love Traditional Medicare’s 2 MN rule. Day’s strength is her ability to ‘operationalize’ complex regulations into teachable components.
Ms Egusquiza is a nationally recognized speaker on continuous quality improvement (CQI), benchmarking, redesigning, reimbursement systems and implementing an operational focus of compliance- both in hospitals and practices. She has been on the AAHAM National Advisory Council, HFMA National Advisory Council, is a past President of the Idaho HFMA Chapter & recently received the Lifetime Achievement Award. She has been highlighted in JCAHO’s Six Hospitals in Search of Excellence, Zimmerman’s Receivable Report, HFMA’s HFM and Patient Account, AHIA Prospective, and numerous healthcare newsletters along with a contributing author to 2006 Health Law and Compliance Update. She received the Idaho Hospital Association “Distinguished Service Award” for her legislative work and training on new indigent law. Attendees at HFMA’s ANI rated her in the top 25% for each year she has presented, earning her the ‘Distinguished Speaker’ award.
Her greatest accomplishments are her four wonderful children and her eight fabulous grandchildren.
What makes her unique? She has been in the trenches with us!
Points of Interest:
Ms Egusquiza is a nationally recognized speaker on continuous quality improvement (CQI), benchmarking, redesigning, reimbursement systems and implementing an operational focus of compliance- both in hospitals and practices. She has been on the AAHAM National Advisory Council, HFMA National Advisory Council, is a past President of the Idaho HFMA Chapter & recently received the Lifetime Achievement Award. She has been highlighted in JCAHO’s Six Hospitals in Search of Excellence, Zimmerman’s Receivable Report, HFMA’s HFM and Patient Account, AHIA Prospective, and numerous healthcare newsletters along with a contributing author to 2006 Health Law and Compliance Update. She received the Idaho Hospital Association “Distinguished Service Award” for her legislative work and training on new indigent law. Attendees at HFMA’s ANI rated her in the top 25% for each year she has presented, earning her the ‘Distinguished Speaker’ award.
Her greatest accomplishments are her four wonderful children and her eight fabulous grandchildren.
What makes her unique? She has been in the trenches with us!
Points of Interest:
- AICPA: Planning Committee member for healthcare, Chair 2004-2011
Speaker at 14 annual conferences, board member 8 years
- AHIA: National conference key note speaker
- HFMA: National faculty member; presenter at ANI; national revenue cycle conference; two-day cluster; CFO Forums; regional conferences with continual evaluations in the top 25% -earning the Distinguished Speaker Award yearly.
- Instructor: College of Southern Idaho, continuing education program on “Understanding the Medicare Benefit.”
- Board of Directors: Special Olympics of Idaho,2003-2007. Secretary 2004
- Contributing Editor; AAHAM Technical Certification Study Guide, revised March 2004; CPAT & CCAT exams
- Co-Chair of national RAC Summit (2009-current)
- Co-Creator of the national Physician Advisor and UR Boot camp (2012-current)
- President and Founder of the Patient Financial Navigator Foundation, Inc, – a Idaho-based family foundation- transforming the hassle factor in healthcare thru education.
3:00 pm
Break
BUILDING BLOCKS OF CONTRACTING
3:20 pm
Value Based and Hot Contract Issues- Payer
Michele Marcum, CHFP
Senior Contract Specialist, Saint Alphonsus Health System and Saint Alphonsus Health Alliance, Formerly in Network Development and Contracting with Humana and Aetna, Boise, ID
Senior Contract Specialist, Saint Alphonsus Health System and Saint Alphonsus Health Alliance, Formerly in Network Development and Contracting with Humana and Aetna, Boise, ID
Michele Marcum has over 30 years of experience serving in a variety of roles in the healthcare finance industry. In addition to experience in payer contracting for health systems and networks, Michele has worked in network development and contracting on the payer side for Humana and Aetna. Prior to moving into the contracting arena, Michele served as Director of Patient Financial Services and Patient Access and worked for a Medicare Fiscal Intermediary.
As Senior Contract Specialist for Saint Alphonsus Health System, and the Saint Alphonsus Health Alliance Network (a clinically integrated network) in southwest Idaho and eastern Oregon. Michele manages the contractual relationships with major payers for the health system and the Alliance with a focus on value based agreements.
Saint Alphonsus Health System, owned by Trinity Health, is a four hospital system with facilities ranging from Critical Access to a ## bed hospital with the only trauma center in the state and a multi-specialty medical group with ## providers. The Saint Alphonsus Health Alliance is a clinically integrated provider network that extends beyond the Saint Alphonsus Health System.
Michele is actively involved with the Healthcare Financial Management Association Idaho Chapter, serving as an officer on the Idaho board, as the Regional Executive for Region 10 and on the National Certification Committee. In addition to other HFMA awards, she has received the Founder’s Medal of Honor award for her service in HFMA.
As Senior Contract Specialist for Saint Alphonsus Health System, and the Saint Alphonsus Health Alliance Network (a clinically integrated network) in southwest Idaho and eastern Oregon. Michele manages the contractual relationships with major payers for the health system and the Alliance with a focus on value based agreements.
Saint Alphonsus Health System, owned by Trinity Health, is a four hospital system with facilities ranging from Critical Access to a ## bed hospital with the only trauma center in the state and a multi-specialty medical group with ## providers. The Saint Alphonsus Health Alliance is a clinically integrated provider network that extends beyond the Saint Alphonsus Health System.
Michele is actively involved with the Healthcare Financial Management Association Idaho Chapter, serving as an officer on the Idaho board, as the Regional Executive for Region 10 and on the National Certification Committee. In addition to other HFMA awards, she has received the Founder’s Medal of Honor award for her service in HFMA.
3:40 pm
Key Revenue Cycle Elements
R. Phillip Baker, MD
Medical Director for Case Management and Physician Advisor, Self Regional Healthcare, Greenwood, SC
Medical Director for Case Management and Physician Advisor, Self Regional Healthcare, Greenwood, SC
After completing his residency at the University Of South Carolina School Of Medicine Dr. Baker was the founding and managing partner in Piedmont Physicians for Women an OB/GYN practice for 32 years. He has extensive background in managed care and contracting while acting as the President of an IPA and Chairman of the Board of a regional PHO. Initially serving as a part time Physician Advisor doing mainly second level reviews took on the role as a full time Physician Advisor and Medical Director for Case Management and CDI in 2014. Responsibilities also include denials management for Self Regional Healthcare a regional hospital in Greenwood, SC. Dr. Baker serves on several committees including Co-Chair of the Finance Committee for My Health First an upstate South Carolina ACO, Corporate Compliance Committee and Post-Acute Care Committee for My Health First, Governmental Affairs Committee ACPA as well as several committees at the South Carolina Hospital Association. He continues to do extensive work with CMS to regulate Medicare Advantage Plans and joined the Board of Directors for the American College of Physician Advisors in 2017. Dr. Baker’s work in the revenue cycle of Self Regional is at the forefront of the new movement to involve clinical expertise to the financial function of the hospital to crossover the clinical and financial functions of the facility to ensure complete and accurate, defensible billing.
4:00 pm
When Not to Contract – What To Consider.
CMS Guidance: What If You Are Not Contacted with a MA Plan?
R. Phillip Baker, MD
Medical Director for Case Management and Physician Advisor, Self Regional Healthcare, Greenwood, SC
Medical Director for Case Management and Physician Advisor, Self Regional Healthcare, Greenwood, SC
After completing his residency at the University Of South Carolina School Of Medicine Dr. Baker was the founding and managing partner in Piedmont Physicians for Women an OB/GYN practice for 32 years. He has extensive background in managed care and contracting while acting as the President of an IPA and Chairman of the Board of a regional PHO. Initially serving as a part time Physician Advisor doing mainly second level reviews took on the role as a full time Physician Advisor and Medical Director for Case Management and CDI in 2014. Responsibilities also include denials management for Self Regional Healthcare a regional hospital in Greenwood, SC. Dr. Baker serves on several committees including Co-Chair of the Finance Committee for My Health First an upstate South Carolina ACO, Corporate Compliance Committee and Post-Acute Care Committee for My Health First, Governmental Affairs Committee ACPA as well as several committees at the South Carolina Hospital Association. He continues to do extensive work with CMS to regulate Medicare Advantage Plans and joined the Board of Directors for the American College of Physician Advisors in 2017. Dr. Baker’s work in the revenue cycle of Self Regional is at the forefront of the new movement to involve clinical expertise to the financial function of the hospital to crossover the clinical and financial functions of the facility to ensure complete and accurate, defensible billing.
4:20 pm
Hot Contracting Issues – Provider Perspective
Michele Marcum, CHFP
Senior Contract Specialist, Saint Alphonsus Health System and Saint Alphonsus Health Alliance, Formerly in Network Development and Contracting with Humana and Aetna, Boise, ID
Senior Contract Specialist, Saint Alphonsus Health System and Saint Alphonsus Health Alliance, Formerly in Network Development and Contracting with Humana and Aetna, Boise, ID
Michele Marcum has over 30 years of experience serving in a variety of roles in the healthcare finance industry. In addition to experience in payer contracting for health systems and networks, Michele has worked in network development and contracting on the payer side for Humana and Aetna. Prior to moving into the contracting arena, Michele served as Director of Patient Financial Services and Patient Access and worked for a Medicare Fiscal Intermediary.
As Senior Contract Specialist for Saint Alphonsus Health System, and the Saint Alphonsus Health Alliance Network (a clinically integrated network) in southwest Idaho and eastern Oregon. Michele manages the contractual relationships with major payers for the health system and the Alliance with a focus on value based agreements.
Saint Alphonsus Health System, owned by Trinity Health, is a four hospital system with facilities ranging from Critical Access to a ## bed hospital with the only trauma center in the state and a multi-specialty medical group with ## providers. The Saint Alphonsus Health Alliance is a clinically integrated provider network that extends beyond the Saint Alphonsus Health System.
Michele is actively involved with the Healthcare Financial Management Association Idaho Chapter, serving as an officer on the Idaho board, as the Regional Executive for Region 10 and on the National Certification Committee. In addition to other HFMA awards, she has received the Founder’s Medal of Honor award for her service in HFMA.
As Senior Contract Specialist for Saint Alphonsus Health System, and the Saint Alphonsus Health Alliance Network (a clinically integrated network) in southwest Idaho and eastern Oregon. Michele manages the contractual relationships with major payers for the health system and the Alliance with a focus on value based agreements.
Saint Alphonsus Health System, owned by Trinity Health, is a four hospital system with facilities ranging from Critical Access to a ## bed hospital with the only trauma center in the state and a multi-specialty medical group with ## providers. The Saint Alphonsus Health Alliance is a clinically integrated provider network that extends beyond the Saint Alphonsus Health System.
Michele is actively involved with the Healthcare Financial Management Association Idaho Chapter, serving as an officer on the Idaho board, as the Regional Executive for Region 10 and on the National Certification Committee. In addition to other HFMA awards, she has received the Founder’s Medal of Honor award for her service in HFMA.
4:30 pm
Next Generation of Contracting
John Montaine, MBA, FHFMA, HRM
Chief Executive Officer, Creative Managed Care Solutions, LLC, San Antonio, TX
Chief Executive Officer, Creative Managed Care Solutions, LLC, San Antonio, TX
John Montaine brings over 30 years of experience in clinical orthopedics, health insurance, and hospital systems to develop strategic and tactical solutions targeted to each hospital systems unique markets and dynamics.
He leads a team of executives with payer experience to work with our clients developing targeted strategies that increase their revenues by negotiating operational and financial improvements in their contracts to achieve their goals.
Prior to consulting, Mr. Montaine served as a senior hospital executive for two multi-facility integrated Texas hospital systems, and he served in senior executive roles developing and running national and regional health plans in Texas and Florida.
Mr. Montaine has been a member of HFMA since 1999 where he achieved the nation’s highest score on HFMA’s certification exam for Managed Care in 2008.
He started in HFMA with the Gulf Coast chapter where he was as an officer, Board member, and committee chair, before moving to the South TX chapter in 2003 where he was the South Texas Chapter President for 2009-10.
He has been awarded the Follmer Bronze, Reeves Silver, and Muncie Gold merit awards and was awarded the Medal of Honor by the South Texas Chapter in 2011.
He continues to serve the South Texas Chapter on the Texas statewide committee and on the Region 9 planning committee.
In addition to his Fellow status in HFMA, Mr. Montaine holds a certification in Risk Management from the American Academy of Health Law and has been a Diplomat of the American Board of Quality Assurance and Utilization Review Physicians since 1996.
He serves on the BOD of the San Antonio Rugby Football Club where he enjoys playing Rugby as time permits, and scuba diving with his wife of over 30 years. They have 3 adult children.
He leads a team of executives with payer experience to work with our clients developing targeted strategies that increase their revenues by negotiating operational and financial improvements in their contracts to achieve their goals.
Prior to consulting, Mr. Montaine served as a senior hospital executive for two multi-facility integrated Texas hospital systems, and he served in senior executive roles developing and running national and regional health plans in Texas and Florida.
Mr. Montaine has been a member of HFMA since 1999 where he achieved the nation’s highest score on HFMA’s certification exam for Managed Care in 2008.
He started in HFMA with the Gulf Coast chapter where he was as an officer, Board member, and committee chair, before moving to the South TX chapter in 2003 where he was the South Texas Chapter President for 2009-10.
He has been awarded the Follmer Bronze, Reeves Silver, and Muncie Gold merit awards and was awarded the Medal of Honor by the South Texas Chapter in 2011.
He continues to serve the South Texas Chapter on the Texas statewide committee and on the Region 9 planning committee.
In addition to his Fellow status in HFMA, Mr. Montaine holds a certification in Risk Management from the American Academy of Health Law and has been a Diplomat of the American Board of Quality Assurance and Utilization Review Physicians since 1996.
He serves on the BOD of the San Antonio Rugby Football Club where he enjoys playing Rugby as time permits, and scuba diving with his wife of over 30 years. They have 3 adult children.
4:50 pm
What 3 Things MA Plans Don’t Want You to Know
Ed Norwood
President and CEO, ERN Enterprises, Inc., President, National Council of Reimbursement Advocacy (NCRA), and CCO, The Reimbursement Advocacy Firm (TRAF), Cypress, CA
President and CEO, ERN Enterprises, Inc., President, National Council of Reimbursement Advocacy (NCRA), and CCO, The Reimbursement Advocacy Firm (TRAF), Cypress, CA
Ed Norwood is President of ERN/The National Council of Reimbursement Advocacy. He has been recognized as a unique and distinctive authority in transitional leadership and administrative laws that govern the healthcare delivery process.
Few have blazed the trail of success in the same inimitable style as Ed. With an entrepreneurial story which is both entertaining and inspiring, Ed has a seasoned, realistic perspective that inspires people: “It’s never too late to become what they might have been” (Eliot).
Multi-faceted, with a creative ability to inspire his audience, Ed combines his healthcare influence and expertise with his passion to help providers advocate for medically appropriate healthcare pursuant to federal and state laws.
Few have blazed the trail of success in the same inimitable style as Ed. With an entrepreneurial story which is both entertaining and inspiring, Ed has a seasoned, realistic perspective that inspires people: “It’s never too late to become what they might have been” (Eliot).
Multi-faceted, with a creative ability to inspire his audience, Ed combines his healthcare influence and expertise with his passion to help providers advocate for medically appropriate healthcare pursuant to federal and state laws.
5:20 pm
Afternoon Faculty Q&A Panel
6:30 pm
Dutch Dinner with Faculty
Plus New This Year: Dining with Dynamo Women – the Power of One
Agenda Links: Preconference | Day 3