Vice President Reimbursement/Regulatory Affairs

James T. Walmsley

Cell 610-***-****

**************@*****.***

SUMMARY: Senior healthcare financial executive with demonstrated success in progressively responsible management positions. Key areas of expertise include all facets of Medicare/Medicaid payment systems across multiple Provider and Physician settings including cost based, PPS, BRVS, RUGS Managed Care and FFS. In-depth understanding and experience in managed care, strategic planning, mergers & acquisitions, Medicare certification, finance, patient accounting, operations, compliance and litigation; was the Corporate Vice President/Director of Reimbursement and Compliance for four of the nation’s largest multi-dimensional healthcare Companies. Extensive Big 4 healthcare and insurance consulting experience.

PROFESSIONAL EXPERIENCE AND SELECTED ACCOMPLISHMENTS

Driscoll Childrens’ Hospital 2023 – 2024

Manager Reimbursement

Assisted with filing of State Supplemental Programs including DSH/UC application

Directed Government Reporting Preparation and filing

AHA/THA Quarterly Filings

Modified Admissions procedures to capture all Medicaid qualified Beneficiaries

Modified admissions procedures to advise of Medicare Benefits for ESRD

Compiled Kidney Transplant statistics

Monitored Physician Time Studies

Provided Revenue Cycle Support

University of Miami Health System 2022 - 2023

Executive Director Reimbursement

Responsible for:

The annual filing of Home Office Statement; Medicare, Medicaid and AHCA Hospital and Organ Procurement Organization (OPO) cost reports.

Preparing quarterly Provider Relief Fund submissions for the Hospital and Physicians Group.

Preparing quarterly reserve analysis.

Responsible for the preparation and submission of 855A Facility Enrolment.

Lead appeal of TEFRA cap application.

Participated in GME appeal.

Responsible for monitoring and advising management of significant changes to government reimbursement regulations.

Vibra Healthcare, Mechanicsburg, PA 2005 - 2022

Senior Vice President Reimbursement and Regulatory Compliance

Participated in the growth from 12 to over 95 Hospitals in an 18 year period:

Revised TEFRA target resulting in $2million additional reimbursement.

Developed strategic initiative for a number of new hospitals to attain profitability in the first year of operations.

Successfully reopened numerous Medicare reports resulting in $3 million in additional LIP payments.

Managed annual filing of 93 Medicare, Medicaid and CA OSHPD reports.

Successfully defended Medicare Bad Debt filings.

Maintained CDM for each hospital to assure compliance with LIP/DSH Outlier regulations.

NOVACARE, INC., King of Prussia, PA 1992 – 2005

Senior Vice President Reimbursement and Regulatory Compliance

Responsible for managing NovaCare’s Medicare revenue. Approximately 80% of the Company’s net revenue was funded directly or indirectly by Medicare. Developed Company-wide strategic initiatives, government reporting policies & procedures and contractual accounting models for the four operating divisions: Hospitals, Contract Services, Clinics and Orthopedic & Prosthetics. Additionally, had responsibility for customer support in matters related to their Medicare reimbursement for NovaCare services.

Redesigned companywide Medicare reporting methodology resulting in increased reimbursement exceeding $35 million.

Successfully led industry’s litigation of HCFA’s initiative to limit reimbursement of Occupational and Speech Therapy services. This litigation resulted in unanimous Circuit Court decisions favorable to the industry and settlements exceeding $60 million.

Successfully litigated a ‘constructive trust’ claim in Bankruptcy Court resulting in a $3.4 million settlement.

Identified and provided the strategic framework for litigation of HCFA’s decision to eliminate the Lower of Cost or Charge carry forward provision. Net revenue impact exceeded $2 million.

Key member of the executive committee responsible for the design, development and implementation of corporate wide PPS organizational strategy.

Provided support to the Compliance Offices in the investigation of numerous complaints.

Provided technical analysis leading to the industry’s proposal for a site-specific add-on to Medicare’s Part B therapy rates.

Developed new product design to respond to customers managed care initiatives.

PRICE WATERHOUSE, Philadelphia, PA 1982 - 1992

Senior Manager MCS

Responsible for practice development and management of a broad range of healthcare consulting and litigation support engagements for the Firm’s Mid-Atlantic Management Consulting Practice. Specialized in Third Party reimbursement, DRG and Physician payment systems Health Care insurance including compliance with Federal and State laws and regulations.

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PROFESSIONAL AFFILIATIONS: National Health Lawyers Association

Healthcare Financial Management Association

EDUCATION: Bachelor of Science - St. Joseph’s University, Philadelphia

Major: Accounting/ Management Marketing

Graduate Courses MBA – Widener University

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