Wayne Gibson is a Senior Managing Director at FTI Consulting and is based in Washington, DC. He is part of the Health Solutions segment. He has 20 years of experience applying economic and financial modeling, data-intensive analysis, and complex claims analyses across numerous industries and in a variety of operational, dispute and compliance matters.
Wayne has assisted health plans, providers, pharmaceutical manufacturers and PBMs with in a variety of matter types including operational improvement and compliance consulting, nationwide class-action litigation, Medicare and Medicaid false claims and sales and marketing investigations, investigations by other government agencies, and arbitration matters. Significant types of matters Mr. Gibson has worked on include:
Risk Adjustment Operational Improvement and Compliance Assessments – assisted Medicare Advantage plans, ACA exchange-based plans, trading partners/vendors, and providers under risk contracts in an end to end assessment and redesign of work flows and data flows, policies and procedures, controls, reporting and forecasting related to their Medicare Advantage and risk adjusted populations. Has also performed reviews of systems and programming logic used to filter encounters to assess compliance with Medicare Advantage and Managed Medicaid requirements. Has worked with clients to develop and implement interim and ‘bridge’ applications that provided added functionality in managing populations subject to risk adjustment. Has supported plans in RADV and other regulatory reviews. Has assisted in contractual disputes regarding payments from health plans to provider groups under shared risk agreements.
Medicare and Medicaid Investigations - assisted a variety of clients including health plans, pharmaceutical manufacturers, institutional providers, diagnostic lab testing companies, and their outside counsel in responding to governmental investigations and in conducting internal investigations related to Medicaid and Medicare false claims and fraud and abuse issues as well as how these issues may impact statutory and SEC reporting. These investigations encompass issues such as reimbursement, pricing, Medical Loss Ratios and cost reporting, and sales and marketing. As part of these investigations has assisted clients and their counsel in discussions with the DOJ, OIG, state Medicaid and regulatory agencies, and the SEC.
Compliance and Operational Reviews – assisted a variety of clients with compliance reviews related to Medicare Advantage, Fee for Service Medicare and Medicaid programs. He has also performed other contractually-mandated reviews, and operational assessments of controls, data and information systems, and relationships with third parties/sub-contractors.
Litigation and Commercial Disputes (Healthcare and Other Industries) – assisted a variety of clients and their outside counsel in defense of nationwide class-action matters, federal and state court litigation, international arbitration, and arbitration and mediation matters. Has developed and submitted expert reports on damages in a number of forums and has testified in arbitrations.
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