Diane Folckemmer

Diane’s professional experience includes:

• Assisted counsel in payer-provider reimbursement disputes related to out-of-network services for professional and facility claims. Reviewed member plan documents and analyzed large volumes of transactional data, including claims data and market reimbursement data.
• Assisted a large hospital system with an internal investigation related to potential systemic up-coding related to services performed by advanced practice providers. Performed data analytics to compare provider information across three separate systems to identify claims at issue.
• Performed detailed reviews of healthcare claims documents in payer-provider reimbursement disputes over various contractual terms and reimbursement. Issues analyzed included compliance with administrative procedures (timely filing, appeals), pricing of services, enrollment/ eligibility, coordination of benefits, medical necessity, etc.
• Assisted a large hospital system with their self-disclosure to the government related to up-coding evaluation and management services. Performed data analytics to identify claims potentially at issue, selected a statistically valid sample per the government’s self-disclosure protocol, assisted with the management of coding reviews, and extrapolated the findings.
• Performed pricing and medical coding reviews of thousands of claims transactions in the TRICARE program in comparison to TMA regulations, Medicare guidance, and provider agreements. Managed a detailed sample review of hundreds of TRICARE claims to evaluate compliance with TMA claims adjudication regulations, including the use of unlisted CPT codes, and performed the extrapolation of overpayments in compliance with Medicare standards and the OIG Self-Disclosure Protocol.
• Reconciled provider billing data with payer claims data to evaluate potential financial exposure under alleged statutory violations. Analyzed hundreds of payer-provider contracts, and programmatically compared the contract pricing terms to the actual payments made by the payer to evaluate damages.
• Assisted healthcare clients with the oversight and management of complex operations programs, including managing the 2015 Risk Adjustment/Reinsurance submissions to HHS for the healthcare exchanges. Created business as usual documentation, including data flows, business process flows, and organizational design charts.
• Provided support to counsel in defending litigation matters on behalf of large pharmacy benefit managers (PBM), including a lawsuit related to the PBM’s compliance with contractual provisions related to the pricing and administration of mail order and retail drug benefits.
• Developed data warehouses to programmatically analyze hundreds of millions of healthcare claims transactions, including health plan, provider, and pharmacy claims data, and produced data in accordance with discovery parameters and settlement notification terms.