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presentation

Paul Rossi

Expertise In: Hospitalist Billing

Name : Paul Rossi
Experience : 5
Specialty : Hospitalist Billing
Location : GreatNeck,NY
Description :

Paul Rossi has established a track record identifying, leading, and executing strategic corporate initiatives related to significant policy, reimbursement, and technology change that have resulted in favorable and measurable revenue enhancement and cost reduction outcomes. He oversaw operational and technology integration of corporate policies. Demonstrated success innovating data mining applications to evaluate root causes, identify opportunities, drive fact-based decisions, and bring context and direction to business initiatives across a broad range of programs.

Skills:

Expertise managing the end-to-end managed care/provider contract life cycle continuum: negotiation, contract modeling/analysis, payer reimbursement system configuration, payment auditing, and contract performance evaluation.

  • Managed care
  • Reimbursement  
  • Medical economics Revenue optimization
  • Payer/provider contract life cycle
  • Contract configuration Network strategy
  • Provider operations
  • Risk-sharing arrangements

Experience:

  • Analyzed utilization and cost data for IPAs under risk capitation. Identified key drivers and presented findings and recommendations for medical cost improvement to senior staff.
  •  Assisted with provider claim payment audits. Provider overpayments identified over $7 million.     
  • Directed Facility Rate and Fee Analysis Departments. Supervised a team of analysts.        
  • Championed one of the largest PPO reimbursement system configuration migrations to date as of June, 2003 for a first-to-market pricer application (TriZetto's NetworX). Directed the implementation of 68 thousand provider contracts impacting over $2 billion in provider claim charges annually. Pricing automation increased from 0% to 94%.
  • Led initiatives to improve operational performance and reduce administrative costs. Managed technology vendors, identified issues/opportunities, defined business requirements, system enhancements/edits, and technical specifications and directed and tested large scale configuration implementations.
  • Managed the configuration and maintenance of all fee schedules and provider contracts; e.g. CMS rate updates, new/renegotiated contracts.
  • Oversaw the technical design of a provider contract modeling and reporting system that forecasted the financial impact of alternative reimbursement scenarios to support national and regional strategic network contracting initiatives.
  • Identified strategic revenue maximization and cost reduction initiatives, projected PMPM financial impact, and presented recommendations to senior staff for corporate policy consideration. Directed or assisted with multiple technology system integration rollouts of new and modified corporate policies impacting claim payments exceeding $30 million per year. Identified alternative provider reimbursement strategies to minimize out-of-network cost exposure and support various corporate medical cost saving programs.
  • Provided operational and technical configuration oversight directing corporate fee schedule consolidation initiative. Conducted reimbursement studies, evaluated new technologies, and managed the consolidation of 450 fee schedules representing $40 million in annual claim payments.
  • Oversaw the configuration of select fee schedules and provider contracts representing $200 million in claim payments annually; e.g. CMS and Medicaid rate updates, new/renegotiated contracts.
  • Conducted provider claim payment audit analyses. Provider payment recoveries over $7 million.
  • Instituted new policy and procedural changes and oversaw the deployment of technology to improve pricing accuracy, automation, and overall operational performance.
  • Headed Finance Managed Care Department. Supervised a team of multidisciplinary managed care staff.               
  • Managed the financial performance of a $45 million a year risk-sharing arrangement. Presented technical information and actionable solutions to limit risk exposure to senior staff.
  • Successfully implemented a comprehensive reporting infrastructure to conduct complex cross-functional analyses of health care data, measure performance, and explain results, and forecast outcomes and medical expense trends.
  • Oversaw a claim audit system that validated the pricing accuracy of $45 million in professional and outpatient facility payments annually prior to payer adjudication. Conducted provider payment audit reviews. Over/underpayments recouped in excess of $1 million.
  • Developed contract modeling utilities to evaluate the financial impact of alternative pricing strategies to support payer contract negotiations and decision making. Negotiated managed care contracts, facilitated implementation, and monitored contracted performance.
  • Managed the financial performance of a $140 million a year global risk-sharing arrangement. Responsible for assuring high quality data analysis in support of strategy development and execution and implemented a reporting system to meet management and drill down reporting needs.
  • Identified actionable opportunities and spearheaded collaborative efforts to maximize reimbursement and reduce medical costs resulting in positive measurable outcomes; e.g. PMPM premium revenue/cost savings, risk pool surpluses, risk score improvement, RAPS recoveries, leakage/utilization reduction, denial rate reduction.
  • Conducted operational assessments, identified systemic root causality impacting revenue cycle operations, and coordinated cross-functional team efforts through the resolution process.
  • Evaluated and negotiated payer contracts. Developed rate modeling reporting tools to project the financial impact of contract proposals.
  • Championed efforts to improve the accurate reporting of members’ health status resulting in enhanced risk adjusted HCC/CRG premium revenue.
  • o Initiated large scale medical chart retrieval for clinical audit review resulting in an annual $6 million retroactive premium revenue recovery.
  • o Identified and assisted in reconciling encounter submission errors resulting in a decrease in ‘non-users’ and an increase in medical premium revenue and fee-for-service collections.
  • Administer the day-to-day tactical reimb