Florentino Buendia's Email Addresses & Phone Numbers

📖 Summary

Payment Innovation Programs/Provider Collaboration Director @ Anthem, Inc. Payment Innovation/Provider Collaboration Programs Director responsible for identifying and coordinating long term provider contracting, payment innovation and reimbursement strategies that support Commercial, Medicare, and Medicaid Lines of business. • Developed Provider Solutions Playbook strategy and process to identify Provider Solutions (i.e. Network Management) strategies that support and tie together goals of Commercial, Medicare and Medicaid lines of business. • Managing Playbook process that includes working with line of business leadership and Provider Solutions leadership. Through this process supported three provider network builds and implementations, and improved alignment of goals for Provider Solutions activities to support the different lines of business. CincinnatiProvider Contracting Director @ Anthem, Inc. Provider Contracting Director responsible for leading or supporting Provider Engagement and Contracting initiatives with a focus on ICD-10 • Created strategy and directed ICD-10 activities for Provider Engagement and Contracting division to reduce company’s risks surrounding incorrect or delayed payments to providers. • Lead company-wide analytics activities to estimate reimbursement impact of the industry change from ICD-09 coding to ICD-10 coding where a .1% change equates to $20-$30 million impact. From January 2011 to March 2015 (4 years 3 months) Cincinnati AreaStaff VP Pricing Development and Support @ Anthem, Inc. Ensure that a provider's contractual and reimbursement terms are implemented in a timely and quality manner on provider reimbursement systems for company. From April 2008 to December 2010 (2 years 9 months) Staff VP, Provider Audit @ Anthem, Inc. Responsible for provider audit and professional reimbursement with over 50 FTEs in 9 states • Improved Provider Audit program by increasing recoveries from $23 million to $44 million in 5 states. Established programs for DRG readmission audits and expanding ancillary audits. • Negotiated Audit terms in contracts with providers as well as negotiated settlements with providers in support of Provider Audit program. • Organized Enterprise Professional Reimbursement and Enterprise Claims Editing teams to establish standard and best practice reimbursement policies and procedures that varied locally. Example of best practice was the standardization of policy on reimbursement of venipuncture which saved over $12 million annually. From January 2007 to March 2008 (1 year 3 months) CincinnatiDirector Provider Audit and Reimbursement @ Anthem, Inc. Director, Provider Audit and Reimbursement responsible for Professional Reimbursement and Provider Audit for Central Region - 5 states. • Enhanced Provider Audit program by increasing recoveries from $14.3 million at end of 2002 to $23 million. Established programs for ancillary and chargemaster audits. • Integrated Anthem Midwest reimbursement policies and procedures with MO and WI reimbursement policies and procedures. Resolved issues of Multi District Litigation from providers. • Consolidated pricing of Not Otherwise Classified (NOC) codes and Pricing Inquiries to my team. Implemented new productivity and quality audit systems. Increased associate productivity by 100% in responding to pricing inquiries going from 1.5 cases to 3 cases per hour. From July 2002 to December 2006 (4 years 6 months) CincinnatiManager, Provider Audit and Reimbursement @ Anthem, Inc. Manager, Provider Audit and Reimbursement responsible for professional reimbursement, provider auditing, and project management for provider contracting functions for Midwest Region – 3 states • Implemented a centralized professional reimbursement team and a clinical editing team for the three states to implement standard Policies and Procedures related to these areas. • Enhanced Anthem Midwest’s Provider Auditing program by increasing recoveries from $7.1 to $14.3 million.• Resolved complex issues involving disparate policies and business rules surrounding pre-certification, site of service, and denied days sanctions in order to implement a 3 state product portfolio. From December 1999 to June 2002 (2 years 7 months) CincinnatiPlanning and Product Development Manager @ Anthem, Inc. Planning and Product Development Manager responsible for managing projects in the Health Care Management (HCM) division. • Directed a cross divisional team to create networks for new managed care products. Ultimately executed contracts with over 30,000 health care providers in 3 states.• Led team to replace Kentucky Fee schedule in Northern Kentucky with Cincinnati Professional Fee Schedule on Kentucky systems. Project savings were $893,000. From July 1996 to November 1999 (3 years 5 months) Project and Product Development Coordinator @ Anthem, Inc. Project and Product Development Coordinator responsible for developing and implementing insurance products for the Individual Markets. • Contracted with brokers to increase product lines such as term and whole life, and fixed annuity products.• Supervised managed project to launch a managed care Medicare Supplemental product from design to implementation phase. From January 1995 to June 1996 (1 year 6 months) Managed Care Specialist and Administrative Resident @ Meridia Hospital Managed Care Specialist and Administrative Resident responsible for problem resolution, and communication to providers in Meridia’s Physician Hospital Organization (PHO) as well as special projects in Health System. • Coordinated the transition of reimbursement for Plan providers from a community based fee schedule to a RBRVS based fee schedule. • Developed and implemented PHO orientation program for office managers • Executed the integration of Total Quality Improvement and Quality Assurance processes.• Negotiated ambulance contract entailing analysis and contracting which reduced ambulance costs by $60,000. From June 1992 to December 1994 (2 years 7 months)