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Dorothy has more than 16 years of experience in managed care and health insurance regulatory compliance and operations. She specializes in regulatory compliance and operations within the managed care and pharmaceutical industries. Her consulting practice during the last six years has focused on the intersection of compliance issues in business relationships among entities in those two industries. Dorothy has designed and implemented compliance programs and regulatory audit preparedness programs for Managed Care Organizations, Pharmaceutical Manufacturers, and Hospitals.
Professional Experience
Formerly, Dorothy was a Director at KPMG and a Medicare Compliance Officer with Kaiser Permanente's corporate office. In that capacity, she was responsible for the design and oversight of the Medicare compliance program for Kaiser Permanente in 13 separate health plans, and she dealt frequently with the Centers for Medicare and Medicaid Services (CMS).
Representative examples of Dorothy's engagements include:
Conducted numerous risk assessments and designed and implemented Medicare Advantage and Part D (MA-PD) and Prescription Drug Program (PDP) compliance and Fraud, Waste, and Abuse programs.
Prepared many CMS MA-PD and PDP applications.
Created compliance program plans, manuals, tools, and training materials for all MA-PD, PDP requirements.
Performed claims and formulary rebate audits of PBMs on behalf of health plans and self-funded employers.
Developed and implemented multi-disciplinary mock regulatory review programs to ensure that managed care plans were adequately prepared for CMS and National Committee for Quality Assurance (NCQA) site reviews.
Performed claims reviews of large- and mid-sized pharmacy benefit managers (PBMs), third party administrators, indemnity plans, employer health and welfare funds, and managed care plans.
Reviewed and performed analyses of numerous health and welfare funds, employee summary plan documents (SPDs), administrative services only (ASO) contracts, pharmaceutical manufacturer and PBM contracts, employee claims and payment records, and provider contracts.
Prepared for and led many successful CMS site visits.
Provided successful departmental and inter-departmental re-engineering services to bring health plans into regulatory compliance and to streamline business operations in all major departments of hospitals and health plans.
Led many successful implementations of new federal, state, and NCQA regulatory requirements and standards.
In addition, Dorothy has testified as an expert witness at deposition, in a state court hearing, and at arbitration.
Education & Certifications
Bachelor of Arts, Psychology/Statistics, Baldwin-Wallace College, Berea, Ohio
Professional Associations
Member, Health Care Compliance Association
Speaking Engagements
Blue Cross and Blue Shield Association Internal Audit and Anti-Fraud conferences on Medicare Part D and Fraud, Waste, and Abuse Issues
Health Care Compliance Association on Medicare Part D Audit Issues
International Institute for Research Pharmaceutical Congress on How to Audit a PBM
Pharmaceutical Education Associates Prescription Drug Pricing Conference on FWA and Drug Pricing Compliance | 