Dorothy DeAngelis

Dorothy’s professional experience includes:

Government Programs Compliance and Operations

• For many of the nation’s largest government and commercial healthcare payors, pharmacy benefit managements (PBMs), retail, and specialty pharmacies, Dorothy assesses risk, controls, implements compliance programs and delegation oversight programs as well as analyzes large complex claims and clinical data sets.
• Conducted “mock” Centers for Medicare, and Medicaid Services (CMS) Program Audit, and Intermediate Sanction validation audits of all Medicare Advantage and Part D key risk areas. The goal of the projects was to provide reports for companies’ senior leaders and CMS that the issues are not likely to recur.
• Implemented numerous First Tier, Downstream, and Related Entity (FDR) oversight programs including pre-contracting assessments and site visits, ongoing auditing and monitoring, and government facing audit protocols.
• Performed in-depth process and system reviews as well as transaction testing of Coverage and Organizational Determinations, Appeals, and Grievances departments across numerous health plans and pharmacy benefit managements (PBMs’) systems and vendors. Issues included Medicare Part B vs. Part D determinations, provider outreach, proper notification, medical necessity, and documentation. Results included developing ongoing auditing and monitoring dashboards for key performance indicators as well as process re-design.
• Performed compliance and operational due diligence related to several potential transactions occurring between entities involved with Medicare Advantage and Medi-Cal.
• Conducted end-to-end process reviews of the entire Medicare Advantage and Part D risk adjustment payment process from encounter and claims data capture and submission to final financial reconciliation with CMS. This work included review of complex claims and capitated encounter data to support large claims for payment to the Federal Government.
• Developed specialized Medicare Risk Adjustment Compliance Programs for several large national health plans. The work included development of key policies and procedures for relevant control points.
• Assisted a large health plan with bringing external pharmacy benefit management (PBM) functions in-house. The work was focused on complex benefit configuration and pre and post system migration testing. Performed extensive system and process walk-throughs of current and post implementation environments and developed detailed member and group benefit and claims scenarios to test the benefits, their system mappings, accumulators, and cost sharing levels. The predecessor system that we helped migrate was RxClaim.

Investigations and Disputes

• Conducted investigations of large MSOs and IPAs processes and systems related to handling of prior authorizations, claims, and provider dispute resolutions under Knox-Keene Act and Medi-Cal regulations.
• Served as consulting expert for a compound pharmacy, and calculated exposure related to pre, and post implementation of NCPDP 5.1, and D.0 related to multi-ingredient compound processing and the use of NDCs for bulk powders across all government payers (Medicare Part D, Medicaid, FEHBP, and Tricare).
• Conducted internal investigation for a large Medicaid False Claims Act matter which included the analysis of large volumes of claims, HEDIS, disease management, enrollment, and premium transactions and data among related and non-related entities to quantify the effect of improper acts or identify trends or biases that may indicate improper acts. This work also included working with the company to help them revise their mainframe claims, enrollment, and clinical system programming to better respond to state Medicaid reporting and documentation requirements pursuant to their contracts with the state.
• Testifying expert in an arbitration matter related to coverage of specialty drugs under the medical versus the outpatient pharmacy benefit.
• Testifying expert related to a False Claims Act (FCA) matter against a large retail pharmacy chain the potentially inflated Usual and Customary (U&C) prices for Medicare Part D versus private pay customers for generic drugs pursuant to a member generic discount program.
• Testifying expert in a FCA matter for a large pharmacy benefit managements (PBM) related to potentially false certifications of Prescription Drug Event (PDE) data related to gender contraindicated drugs, missing, or invalid NPIs and obsolete or expired NDCs.
• Testifying expert in an arbitration related to the termination of a Medicare Part D contract by CMS and the roles and responsibilities of FDRs in Prior Authorizations, edits, and formulary administration.