His 17 years of experience spans a variety of clients including financial institutions, retailers, manufacturers, health insurers, managed care organizations, physician enterprises, health systems, and pharmacy benefit managers, as well as pharmaceutical manufacturers and wholesalers. Joseph has assisted these organizations with issues related to analytics, data validation audits, information systems capability assessments, large-volume claims billing and payment disputes (often involving automated claims auditing), prompt-payment, fraud, breach of contract, and contractor performance. Joseph has extensive experience developing and managing business and technical requirements involving data warehousing, healthcare claims analysis, and data mining as they relate to healthcare payers’ claim systems and auditing programs.
- Conducted numerous compliance audits focused on contractor performance for hospitals and health plans, as well as Centers for Medicare & Medicaid Services (CMS) Program Audits, Data Validation Audits, and Information Systems Capabilities Assessments for Medicare and Medicaid plan sponsors. Some audits included the review for accuracy of procedural (including CPT, ICD-9, and revenue) code changes by contractors, the appropriateness of those code changes, and the use of automated bridge routines. Other matters evaluated the contractual responsibilities and procedural accurateness of a contractor’s efforts in identifying supplemental diagnosis codes (i.e., ICD-9) from medical record documentation and the subsequent submissions to CMS for risk adjustment and reimbursement. For a Fortune 50 payer client, Joseph provided process improvement services related to extensive updates to the client’s existing Alternate Submission Method SAS/SQL logic and technical system enhancements to enact new levels of error handling (e.g., eligibility handling), end-to-end record level tracking, and real-time client reporting for encounters and diagnoses submitted to CMS for Medicare Risk Adjustment purposes.
- Conducted numerous investigations and provided privileged consulting on matters that involved allegations of fraud and/or misconduct. This included cases that involved contractor misconduct, inventory shrinkage anomalies, and billing and payment inconsistencies, as well as falsification of pharmaceutical prescription fill turnaround times. Oftentimes these cases required large-scale transactional data analysis to detect the aberrant patterns and trends that are atypical of normal business operations. In one whistleblower case, Joseph analyzed over six terabytes of claims data to uncover and isolate the transactions with fraudulent patterns to substantiate any related misconduct within those facilities.
- Led hospital and health system performance improvements and analytics matters through the development of robust performance analytics and teams responsible for the data requirements gathering, project management, collection, validation, analytics, and visualizations to support the revenue-generating and cost-saving opportunities associated with performance improvement, including areas such as clinical, labor productivity, supply chain, revenue cycle, and physician enterprise. Joseph is a thought leader in analytics development, process standardization, and data flow automation, all of which allow for efficient review, analysis, and reporting of EHR/EMR system information (i.e., EPIC, Meditech, Cerner) for all stakeholders, including client personnel, executives, and internal service line consultants. In this capacity, he worked with a diverse set of children’s hospitals, large integrated health systems, and regional hospitals throughout the country.
- Managed IT due diligence and management analytics matters for private equity clients and their portfolio companies, Joseph conducted in-depth technical reviews and due diligence of IT organization, architecture, infrastructure, and customer relationship management platforms. For these clients, the goal was to evaluate the viability of the target companies’ service and/or product offering(s) from an information technology, analytics, and data perspective and to help the client determine whether the capabilities warrant the financial investment by potential investors. In addition, Joseph conducted key performance indicator mappings from revenue, cost, and other operational metrics leveraging the company’s existing workflow tools and databases.
- Handled operational analytics matters utilizing, mapping, and managing data from enterprise data warehouses, billing, claims, and decision support systems. In addition, he is well-versed in developing and managing databases in Microsoft SQL Server and other relational database programs. His skills include being able to process large volumes of data in an efficient manner, identify and work through data integrity issues, and standardize data across disparate sources to allow for meaningful and effective analyses and reporting to the organization. Joseph led engagements that performed large-scale and complex analyses of hundreds of millions of data points making up dozens of terabytes of operational and transactional data. Oftentimes, the analytics become executive-level dashboards and reporting to help the organizations’ stakeholders identify areas of opportunity and address major operating concerns.