KPMG US

As a Principal at KPMG, my role revolves around using my management consulting skills to provide financial analysis and strategic business planning guidance. I work closely with healthcare executives, empowering them to navigate the complexities of budgeting within the evolving landscape of healthcare payments. By cultivating leadership development and leveraging my analytical skills, I help these professionals sustain and grow their organizations effectively.

Principal

Managing Director

Director

American Heart Association

As a member of the executive leadership team for the American Heart Association's Heart Walk, I leverage my skills in management consulting and leadership development to drive fundraising efforts, community engagement, and awareness campaigns. I am deeply involved in budgeting and financial planning for fundraising activities, utilizing my analytical skills to maximize efficiency and reach. My role is focused on raising awareness about the impact of heart disease and stroke in Maryland, forging strong connections with the community, and providing strategic guidance to optimize our mission's impact.

Heart Walk Executive Leadership Team Member

Healthcare Financial Management Association (HFMA)

In my previous role as President of the Maryland Chapter of the Healthcare Financial Management Association (HFMA), I led a professional network of financial executives in the healthcare sector. I applied my management consulting expertise and financial analysis skills to oversee educational development and foster leadership development within the organization. A significant part of my work involved guiding members in comprehending and navigating the intricacies of healthcare payments, budgeting, and analytical techniques, thus contributing to their individual growth and the overall advancement of the chapter.

President of Maryland Chapter of HFMA

I am a Principal at KPMG, where I use my management consulting skills to provide financial analysis and strategic business planning guidance to healthcare executives. With a Masters of Health Science from The Johns Hopkins University, I have a strong background in health finance and management, which enables me to navigate the complexities of budgeting within the evolving landscape of healthcare payments.

My role is focused on empowering healthcare professionals to sustain and grow their organizations effectively, by cultivating leadership development and leveraging my analytical skills. I have delivered keynote speeches at healthcare conferences, trained professionals at Johns Hopkins Bloomberg School of Public Health, and advised executives on payment policy design for maximum community impact. I am also a member of the executive leadership team for the American Heart Association's Heart Walk, where I drive fundraising efforts, community engagement, and awareness campaigns. I am passionate about collaborating for a sustainable future.

James Case

A versatile and strategic executive in the healthcare industry. Proven innovator with unique expertise at the intersection of operations, finance, technology, and clinical management. Experience includes companies ranging from start-ups to industry giants.

Clear strategic vision and sense of urgency. Substantial P&L experience. Talent for completing rapid and comprehensive assessment of complex situations, and leading teams to create and implement effective solutions. Results-driven, customer-focused, financially, and technically savvy. 

Brings a broad and deep subject matter expertise in managed care from a payer and a provider perspective and across all industry segments including Medicare, Medicaid, Commercial and Self-Funded lines. 

CORPORATE LEADERSHIP
◆ EVP of Healthcare Delivery, Capital Blue Cross, Harrisburg, PA 
◆ COO, PreferredOne, Golden Valley, MN (sold to United Healthcare)
◆ COO, UNC Health Alliance, UNC Healthcare, Chapel Hill, NC
◆ President, North American Medical Management, Chicago, IL (sold to Optum)
◆ Founder/CEO Dynamic Grape Companies, Mequon, WI 

BOARD SERVICE / ADVISORY / OPERATING PARTNER
◆ Advisory Board Member, Stellar Health
◆ Advisory Board Member, Guardiant Health
◆ Board Member, HC Systems, Bathroom Appliance Innovation
◆ Board Secretary, Minnesota Spay and Neuter Assistance Program 
◆ Commissioner, Minnesota Combat Sports Commission
◆ Former Board Member, Minnesota Council of Health Plans

WOMEN BUSINESS LEADERS of HEALTHCARE | www.wbl.org
◆ Member of the premier network of women executives across the healthcare industry. Members are able to move their companies forward, advance their careers, and make a true impact on the healthcare industry.

Board of Directors Level Leadership |Industry Innovator | Financial & Operational Turnarounds | Growth & Profitability Driver | Financial, IT & Clinical Integration | Strategic & Operational Development | Business Transformation | Consultative Sales & Marketing | Technology Commercialization | New Business Development | Compensation & Contracting Strategies | Value Based Care | Advisor | Product Design | Population Health | Pharmacy | Analytics | Care Management | Coaching | Mentoring

Stacy Mays

I’m probably one of the only people in America who could untangle this.

And I know exactly what went wrong.

The harder part?
Getting three separate healthcare organizations to each do their part to fix it.

Here’s the situation 👇

A family member has coverage through a BUCA carrier.
A few weeks ago, she had multiple lab tests done — all preventive services.

• In-network provider
• Sent to a national lab (also in-network)

This week she received an EOB.

👉 4 of 5 labs denied
👉 $600 member responsibility
👉 Correct responsibility: $0

One lab was paid. Four were not.

That didn’t make sense.

So I called the carrier.

To their credit, the rep was helpful and confirmed what I suspected:
• The ICD-10 code used was appropriate for one CPT code
• That same diagnosis code was applied to all five labs
• Result: 4 denials

Next call: the national lab.

Their message is clear:

“Diagnosis codes are the responsibility of the submitting provider.”

Sounds reasonable… except for one thing.

I tracked down the lab’s submission form.

Guess what?

❌ Only one diagnosis code field
❌ No way to pair ICD-10 codes to individual CPT codes

In other words:
It is structurally impossible to submit these labs correctly so they pay as preventive.

Next stop: the university health system billing office.

They told me:

“We don’t do office-based labs. You’ll need to call the PCP office.”

Which won’t help—because the PCP entered the code exactly as instructed, using the only field available.

So here we are.

To fix this:
• The national lab must submit a corrected claim
• The PCP office must document that:
– The diagnosis code was correct for Lab #1
– Different diagnosis codes are required for Labs #2–#5

Three organizations.
One patient.
Zero dollars should be owed.

At this point, a formal appeal may be the only path forward.

I’ll keep you posted.

This isn’t a coverage problem.
It’s a workflow problem.
Who’s fixing it?

Architect of Market Innovation | Catalyst for Culture & Value Creation | Senior Executive| Board Member

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