For more than 21 years, Emily has provided health care consulting and audit work, including eligibility reviews, performance evaluations, internal control reviews, disproportionate share hospital (DSH) audits and consulting, nursing facility audits, hospital audits, and claim and billing reviews for Alabama, Delaware, Illinois, Indiana, Kentucky, Michigan, Mississippi, North Dakota, Ohio, and South Carolina. She has extensive experience auditing and consulting for the Office of Inspector General of the U.S. Department of Health and Human Services, and the Centers for Medicare & Medicaid Services (CMS). She has served as an expert witness for the Ohio Department of Job and Family Services and the Mississippi Division of Medicaid, and has provided expert services to the southern district of the U.S. Department of Justice.
Emily brings vast experience in audits of eligibility. She is the Eligibility Review Manager as part of the national Eligibility Review Contractor (ERC) for CMS, responsible for completion of eligibility reviews for the Payment Error Rate Measurement (PERM). As the Eligibility Review Manager, she manages the eligible review processes that cover the planning, review, and reporting phases.
She had an integral part of the Eligibility Support Contractor (ESC) reviews, initiated by CMS, to obtain information to make changes in future PERM methodology. The revisions of the regulation and procedures were necessitated by eligibility processing changes that followed the Affordable Care Act (ACA). She managed the eligibility preview process for states participating in the ESC pilots, including the Medicaid agencies of Delaware, the District of Columbia, Kentucky, Massachusetts, and Michigan. Emily helped identify areas of change and assisted in the design of reporting tools and standard operating procedures for CMS in a consulting role.
Prior to the ERC and the ESC projects, Emily was the project leader for the eligibility reviews performed since 2008 on behalf of the Delaware Department of Health and Human Services, the Kentucky Cabinet for Health and Family Services, the Michigan Division of Health and Human Services, and the Mississippi Division of Medicaid. In addition to state-specific eligibility projects, she was also the project manager of three CMS-approved mini-PERM engagements for Michigan and CMS-mandated Eligibility Review Pilots for fiscal years 2014 through 2017 for Delaware, Kentucky, and Michigan.
- Eligibility analysis for PERM.
- Audits of hospital uninsured claims for DSH program.
- Medicaid audits.
- Medicare audits of hospitals.
- Billing reviews and audits of fiscal intermediaries and carriers.
- Performance evaluations of governmental entities.
- Analysis of internal controls and processes.
- Risk assessments.
- Expert witness in the areas of Medicaid and Medicare reimbursement systems.
“What we do is important. Millions of people depend on the government health care programs our clients provide. That’s why we always strive to be the best. We know people are counting on us. “
— Emily Wale