Kanika Sabor

Kanika’s professional experience includes:

Healthcare and Risk Adjustment Operations

• Served as a risk adjustment subject matter expert relating to Medicare Advantage (MA) operational programs with a large payer organization.
• Built and ran a comprehensive national retrospective chart review program for complex payer owned/affiliated care delivery organizations.
• Implemented new risk adjustment programs with payers and providers including but not limited to data predictive modeling and application of natural language processing for improved compliance and cost efficiency

Payer Compliance, Investigations and Disputes

• Consulted with a large health plan to provide an end-to-end assessment of their risk adjustment program, including detailed MA data analysis, compliance education and implementation of recommendations in various risk areas.
• Lead a risk adjustment validation audit for a state exchange in order to assist with transfer payment calculations as well as provide feedback and reporting to insurance carriers participating in the exchange.
• Provided large payer client with quantitative and complex analyses with regards to an internal investigation on processing Medicare Advantage data in compliance with CMS regulatory standards and industry best practices. Worked with the client to provide structured weekly reporting, statistics and trending using large submissions data sets.
• Lead efforts to assess validity of Medicare Advantage submissions via chart review for internal and external counsel of a large payer. Tested internal sampling and auditing methodologies as well as facilitated chart review of selected samples by medical coders. Facilitated the client’s fulfillment of contractual obligations to vendors, clients, and government entities.
• Provided analytical support to outside counsel for multiple payer clients that were protesting the award of a state contract. Provided research and detailed quantitative analyses for expert testimony supporting the reversal and rescoring of the unjustly awarded contract.
• Worked with a payer client to provide compliance risk assessment support related to a potential acquisition with relation to Medicare Advantage
• Performed comprehensive consulting engagement to educate payer client personnel regarding best practices in the processing of Medicare Advantage data. Provided expertise and feedback on internal policies, business rules, and suggested/tested system updates implemented.

Provider Compliance, Investigations and Disputes

• Managed engagement for a large provider group and their outside counsel in order to assess their potential financial risk as well as design correction measures with regards to discovered issues in pre and post transactional coding and compliance related to Medicare Advantage.
• Lead engagement to provide services with payer owned physician groups to support their Medicare Advantage submissions and maximize their financial return. Worked to identify submissions with errors, assess solutions to remediate correctable errors and calculate potential risk adjustment factor (RAF) lift and financial estimates related to the remediation efforts
• Managed an engagement to create statistical sampling plans and coding error assessments for a physician group performing due diligence in relation to a planned acquisition.

Health Services and Pharmacy

• Provided a managed care organization with analyses around identification, reconciliation, and reprocessing of invalid Medicare Advantage submissions to CMS and the quantification of potential repayments related those submissions.
• Partnered closely with internal client personnel from a health services organization to establish and conduct claims verification review for Medicare Advantage claims. Assessed accuracy and fulfillment of industry best practices and government obligations by recreating and improving the process through data flow analysis.
• Consulted for outside counsel with relation to pharmaceutical average wholesale price (“AWP”) litigation for both branded and generic pharmaceutical manufacturers facing state lawsuits based upon industry pricing practices.
• Worked with outside counsel for a large retail pharmacy to provide data management, analytics support, and potential damages calculations associated with a qui tam complaint
• Managed engagement for a retail pharmacy’s internal data and compliance teams, including identification and collection of transactional data, creation of sensitivity and exposure analyses, as well as summary models for use in disclosing the client’s exposure to the relevant parties in dispute.
• Performed damage calculations and various scenario analyses for discussion of settlement possibilities to counsel related to standardized pharmaceutical pricing information. Provided support in identification, collection, review, and analysis of transactional sales data.