Jeffrey Low

As a consultant, Jeff has served as a pharmacy expert witness, subject matter expert on the opioid epidemic and Independent Review Organizations, and pharmacy claims audits. Additionally, Jeff has worked with large health systems to enhance the delivery of their compliance programs implementing policies and procedures and development of oversight and monitoring methodologies. He has facilitated many process improvement initiatives in the health plan space to increase the efficiency and effectiveness of operational delivery models.

As a practicing pharmacist, Jeff has served in direct patient care roles working with patients and providers in retail and long-term care pharmacy settings, additionally in health plans (Managed Medicaid and Medicare), facilitating multidisciplinary efforts through nursing, mental health, physician, and network capacities.

Jeff’s professional experience includes:

• PBM Engagement: Project leader and clinical expert for the migration of a large consolidation of pharmacy practices within a PBM and health plan for Medicare and Medicaid product lines of business. Development of business case of financial and operational modeling of best practices for consolidation efforts related to transitioning of services and adequate staffing models/reduction in force while ensuring these efforts are aligned with regulatory standards.
• Pharmacy Expert Witness: Retained expert for dispute between PBM and insurance carrier related to pharmacy claims from compounding pharmacies; requiring interpretation of federal regulatory provisions of drug compounding as per the Food Drug and Cosmetic Act and State government rules, payment analysis of compounding claims, contract interpretation between the PBM and the insurance carrier, and adjudication system logic review compared to industry application of compound claim billing submission processes.
• Medicare Part D Mock Audits: Engagement leader in Medicare Part D Mock Audits identifying key risk areas related to administration and operational processes in Coverage Determinations, Redeterminations/Appeals, Grievances, and customer service. Provide improvement recommendations and solutions to rectify areas of compliance risk.
• Medicare Part C Appeals: Re-established a Medicare Part C appeals department for a MA-PD, by developing new policies and procedures and a training program surrounding compliance and operational aspects of the job functions for current and new staff.
• Affordable Care Act Compliance Program: Created a compliance program to ensure monitoring, auditing, and policies and procedures were administered routinely across the departmental functions for a large health plan.
• Health Plan Investigation: Led investigation and audit on behalf of a state department of healthcare into a large health plan’s delivery of grievance and appeal processes which were not in compliance with state rules and regulations. Performed data analysis to measure operational performance, reviewed work models, and conducted interviews of key staff members to identify breakdowns in processes and opportunities causing the health plan to be out of compliance with standards of the state. This information was used by the state to enforce disciplinary actions.
• Pharmacy Systems Strategic and Operations Assessment: Review of pharmacy systems used by a health plan to determine consolidation strategies and increase effectiveness in delivering utilization management programs for their patient and provider communities. Compared to best industry practices to provide recommendations and cost containment approaches.
• Independent Review Organization: Serving as a member of an independent review organization (corporate integrity agreement by the office of inspector general) directing action plans for a pharmacy who was discovered to have dispensing discrepancies of prescriptions paid for by federal programs. Assist with identifying opportunities in operational breakdowns in process which contribute with inaccurate claim submissions.
• Operational Assessment: Retail pharmacy chain and assist with developing comprehensive workflow documentation, policy and procedures, job aids, and alignment with state board of pharmacy regulations. This effort also educated the district management of the pharmacy chain on education strategies and deliverables to each pharmacy in the region to ensure consistent and repeatable processes were implemented across the organization.
• Retail Pharmacy Opioid Review: Evaluation of the dispensing of opioids and other controlled substances related to a federal and state investigation. Review of pharmacy claims data to identify trends and dispensing patterns correlated to sales of opioids/controlled substances, billing parameters (insurance versus cash), and trend analysis of patients and prescribers.
• Medicare Part D Consultation: Ongoing consultation to a national pharmacy benefits manager regarding all compliance related topics surrounding Medicare and Medicare/Medicaid ranging from formulary administration, coverage determinations and appeals, industry best practices, and coordination of benefits.