Rafael Gonzalez, Esq. | President, Settlement Solutions
Rafael Gonzalez is President of UnitedHealth Group/Optum’s Workers Compensation and Auto No-Fault (OWCA) Settlement Solutions, where he is responsible for all aspects of Medicare and Medicaid compliance issues, including Mandatory Insurer Reporting, Conditional Payment Resolution, Medicare Set Asides, MSA Post Settlement Administration, Third Party Lien Reimbursement and Special Needs Trusts Administration.
Rafael has over 35 years of experience in the auto, liability, no-fault, and workers’ compensation insurance industries. He has written extensively on liability, workers’ compensation, social security, and Medicare/Medicaid issues. He has also taught these subject matters at several law schools and medical schools in Florida. He continues to lecture throughout the country on these topics, as well as the interplay of these with the Affordable Care Act.
Over the last 30 years, Rafael has been recognized by City of Tampa Mayor Pam Iorio and Hillsborough County Commissioner Ronda Storm for his work on behalf of the Hispanic community in Tampa and Hillsborough County. He was awarded the Governors Appreciation Award by Governors Bob Martinez and Jeb Bush for his work in improving Florida’s workers compensation system. He was awarded the Governors Leadership Award by Governor Charlie Crist for his work in improving Florida’s Medicaid system. He was awarded Florida’s Distinguished Service Award by US Senator Mel Martinez for his work and advocacy to improve the US Social Security disability system. He has also been awarded the Presidential National Service Award by President George W. Bush for his work on improving the Medicare Secondary Payer system through the addition of the Mandatory Insurer Reporting process, and by President Back Obama for his work and support of the Affordable Care Act.
Rafael is active on social media. He is owner and manager of several LinkedIn groups, including Medicare and Medicaid Compliance (7,000 members), Medicare Mandatory Reporting, Medicare Conditional Payments, Medicare Set Aside Allocations, Medicare Set Aside Administration (3,500 members), Florida Workers Compensation (2,500 members), Social Security Benefits (1,500 members), Hispanic Issues and Demographics (500 members), and Affordable Care Act Compliance (250 members). Rafael is also active on Twitter with 2,000 followers and Facebook with 1,000 friends.
Born in Havana, Cuba, Rafael and his family escaped communism to Madrid, Spain, and ultimate immigrated to the US. He owes everything he has achieved to his mother, Miriam Lera. Her love and sacrifice have allowed him to live in freedom, succeed and prosper. Rafael graduated from Miami Senior High School, received his Bachelor of Science degree from the University of Florida and his Jurisprudence Doctorate degree from the Florida State University (Go Noles!!! FSU!!!) He lives in Lithia, Florida with the love of his life, his wife Lisa, and his greatest pride, his two sons, Alex and Andres.
Lorenzo Garza | Manager of Operations
Lorenzo Garza is Manager of Operations at Optum Workers Compensation and Auto No-Fault Settlement Solutions. He is responsible for the daily operations of the Settlement Solutions organization, including Intake, MSA Submission, MSA Development, and Conditional Payment Recovery and Resolution. With a dedicated staff comprised of industry experts, registered nurses, attorneys, and pharmacists, daily activity includes proactive partnership with clients, CMS, WCRC, BCRC, and CRC entities with emphasis on the accurate and timely management of all cases delegated and completed within regulatory, medical, and contractual requirements.
Prior to joining Optum, Lorenzo served in multiple national and global organizations and has more than 25 years of health care operations experience. In addition to his workers’ compensation experience, Lorenzo has also lead management activity within start-up organizations, commercial insurance, HMO, TPA, BPO, hospital, and provider-based environments, and has provided direct oversight of all claims, quality management, member and provider call center, accounts receivable, enrollment, provider credentialing, account management, project management, reporting & analytics, and regulatory compliance requirements.
A native of Houston, Texas, Lorenzo has also served honorably in the U.S Naval Submarine Force. Lorenzo holds a Bachelor of Science in Business, and is a graduate from Albright College with Highest of Honors.
Frank Fairchok | Vice President, Medicare Compliance Reporting & Development
Frank Fairchok is Vice President of Medicare Compliance Reporting and Development for Optum Settlement Solutions. He has nine years of experience in MMSEA Section 111 reporting and Medicare Secondary Payer compliance. In his expanded role, Frank helps formulate strategic direction and drive new product and technology-driven solutions for our clients. Frank previously managed MedicareConnect℠, Optum’s proprietary platform for Non-Group Health Plan reporting requirements mandated by Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007.
With almost thirty years of experiencing crossing over the financial, telecommunication and workers’ compensation industries, Frank has a deep background in contract administration, order management, billing, revenue recognition and data management. He has worked for global multinational companies such as AT&T, Orange, and now the UnitedHealth Group family of companies at Optum.
Frank knows the work his team performs for Optum clients in the area of Section 111 reporting plays a critical role in the Medicare Secondary Payer processes. He realizes the data must reflect an accurate picture to not only protect Medicare’s interest in the claim, but also to protect his clients from absorbing costs beyond their legal responsibility. Frank appreciates having a team of people handling the day-to-day operation of MedicareConnect with dedication, tenacity and, very importantly, a deep understanding of this area of Medicare compliance. He is also grateful that his team has been with the MedicareConnect program since the go-live of reporting to Medicare in 2011—or earlier. In a world of call routing and inconsistent customer service, our clients have the comfort of hearing the same voices and knowing they are in great hands when they need to contact us.
Frank has a Bachelor of Applied Science in Technology Management from St. Petersburg College and resides in Tampa, FL.
Mendi Benbrahim, MSCC | MSA Production Manager
Mendi Benbrahim is MSA Production Manager at Optum Workers’ Compensation and Auto No-fault Settlement Solutions. As the MSA Production Manager, Mendi is responsible for providing/overseeing the accurate completion of the requested product and providing optimal service delivery. Mendi is responsible for the interviewing, hiring, and training of MSA production staff. Mendi is responsible for reviewing and informing clients of major Red Book value medication cost reductions, which could assist with settlement. Mendi is responsible for multiple pilot programs and project management of new products/processes. She brings more than six years of experience in leadership, more than nine years of MSP experience, and more than 16 years of WC claims handling experience.
Mendi holds a Bachelors degree in Biology with a minor in Wellness from the University of South Florida. While at USF, Mendi was in the sport medicine/athletic
training program assisting the Women’s volleyball team as well as men’s and women’s tennis. Mendi’s previous employment included handling high-exposure medical cases, catastrophic cases, and life pension files with strong emphasis on catastrophic case reserving/settling, which enabled her to provide an accurate work product quickly and efficiently. Mendi was a student athlete, so she believes in the value of team work, integrity and recognition within her department. Mendi recently completed the UHG Emerging Leader Program.
Donna Mize, MSCC | MSA Submissions Supervisor
Donna Mize is the Supervisor of MSA Submissions at Optum Settlement Solutions and
manages a team of highly experienced MSA Specialists and Coordinators. Donna has over 30 years of experience in the workers’ compensation industry and
liability claims, with the past 16 years focusing on Medicare Secondary Payer (MSP) compliance. Donna has held multiple key positions within the Settlement
Solutions organization, including quality control, training, and various management positions. She is Medicare Set Aside Consultant Certified (MSCC). Prior to joining Optum, Donna was a workers’ compensation claims supervisor with a national insurance company and attended the University of South Florida.
Donna began her career in the insurance industry in general health and shortly transferred to workers’ compensation adjusting, followed by liability claims adjusting and supervision. She has been a part of the MSA industry since its inception. Working in the industry from the very beginning has lead to a vast wealth of knowledge, close relationships with CMS representatives and amazing experience in all aspects of MSP compliance. She has also worked with all three work comp review contractors (WCRC), and all reference guides published by CMS. Under her leadership, the MSA submissions team reviews every WCMSA, advising our clients on best practice and results prior to submitting an MSA to CMS for approval. Donna’s team is also responsible for Resubmissions and Amended Reviews, saving our clients millions of dollars on an annual basis.
Ruth Fantham | Conditional Payments Supervisor
Ruth Fantham is the Supervisor of the Conditional Payment team at Optum Workers Compensation and Auto No-Fault Settlement Solutions. In her role, Ruth oversees verification, analysis and dispute for traditional Medicare, Medicare Advantage Plans, Prescription Drug Plans, and Medicaid third-party liability conditional payment debts. Ruth attended Herefordshire Technical College in England, and possesses a strong background as a Workers’ Compensation adjuster and supervisor, specifically focusing on catastrophic injuries. Her strengths include a strong technical background and knowledge in identifying medical diagnosis and conditions, statutory, regulatory and legal defenses. Within her role, she continues to pro-actively develop valuable partnerships within the Medicare Secondary Payer arena, focusing on issue resolution with the Commercial Repayment Center and Benefits Coordination and Recovery Center. She provides a comprehensive, thorough and detailed work product by identifying related and unrelated conditional payments, and therefore maximizing client savings. Ruth also oversees all Requests for Redetermination, Request for Reconsideration, Request for ALJ Hearings, Request for Reviews by Medicare Appeals Council, and Request for Remand/Request for Refund by US Treasury.
Brenda Smith, MSCC, CMSP | Manager, Medicare Mitigation Unit
Brenda Smith serves as Manager of the Medicare Mitigation Unit with responsibility for the oversight of Optum Settlement Solutions’ clinical cost mitigation programs and manages a team of clinical pharmacists, registered nurses, and support staff. Additionally, she has oversight of our internal Quality Control program. Brenda has over twenty five years of experience in the workers’ compensation industry and has focused on the Medicare Set-Aside business for the last thirteen years. Prior to joining Optum, Brenda was a workers’ compensation claims supervisor with responsibility for a team of both technical and support staff. Brenda holds a Bachelors degree in Psychology and holds Medicare Set-Aside Consultant Certified (MSCC) and Certified Medicare Secondary Payer Professional (CMSP) certifications.
Over the last 13 years, Brenda has had experience in all aspects of Medicare Secondary Payer (MSP) compliance, including conditional payments, Medicare Set-Asides (MSA), Section 111 reporting, and our quality control program. Her past experience with all aspects of MSP compliance provides a complete understanding of the issues our clients face in regard to claim settlement. In her current position as Manager of the Medicare Mitigation Unit, she is able to utilize the clinical expertise of her team of pharmacists and nurses to provide action plans specific to each case which can potentially optimize care while also being cost effective. Our clinical mitigation services/program allows clients to identify and address cost drivers that may prohibit settlement as well as review prescription medications and other treatment items that may not be recommended according to clinical standards of practice in order to explore options, with the overall goal to improve patient care while utilizing the most cost effective and clinically appreciate regimen. Taking a hard clinical look at the claimant’s treatment prior to settlement/MSA will allow the client to address any clinical or cost related issues or concerns and maximize the potential for case settlement with an accurate and reasonable MSA.
Lavonya Chapman, Esq., RN, CMSP | Medicare Secondary Payer Compliance Counsel
As Medicare Secondary Payer Compliance Counsel at Optum Settlement Solutions, she is as a consultant on Medicare Secondary Payer (MSP) claim compliance issues, including Mandatory Insurer Reporting, ICD injury code reporting, Conditional Payment Resolution, Medicare Set-Aside Allocations, CMS approval and professional administration.
Prior to joining Optum in 2014, Lavonya served as director of MSP compliance for Arthur J. Gallagher & Company for 14 years. She was also the claim director for a new liability captive in which nearly all the claimants/plaintiffs were Medicare beneficiaries or dual eligible. Additionally, Lavonya has experience in private law practice, litigating medical malpractice, premises and auto liability claims as well as workers compensation cases. She taught pharmacology for many years at the University of Alabama at Birmingham, and was a utilization review and HIPAA consultant for the Alabama Hospital Association.
Lavonya presents on all aspects of the Medicare Secondary Payer Act as it pertains to claim compliance involving all type of claims. She is a licensed registered nurse, an attorney licensed in both Alabama and Florida, and a certified Medicare Secondary Payer Professional.
Paul Hepler, MSCC | Intake Supervisor
Paul is the Intake Supervisor for Optum Workers Compensation and Auto No-Fault Settlement Solutions. He has over 15 years of experience in the workers’ compensation industry with the last eight years focused on Medicare Set-Aside and Conditional Payment compliance solutions, as well as clinical cost containment solutions.
Paul’s responsibilities include overseeing all incoming referrals and documentation, coordinating the daily operations of the mail/intake unit by prioritizing and assigning workflow that allows the business unit to meet key performance standards, working with internal and external customers to identify and resolve procedural deficiencies to reduce customer service issues, creating/developing process workflows, ensuring data integrity of information entered into all computer systems utilized.
Paul is a subject matter expert of Client Profiles, the application used as the main database for our Settlement Solutions organization. He has excellent knowledge in all other network/system aspects, oversees vendor relationships, is the leader for special programs like letter forwarding, and works with management team to collect data to formulate departmental staffing needs.
He is MSCC certified and was awarded company-wide 4th Quarter 2015 Recognition Award.
Evelio Prieto, Pharm.D. | Clinical Pharmacist
Evelio Prieto is a pharmacist and consultant pharmacist registered in the state of Florida. He is a graduate of the University of Florida College of Pharmacy where he earned a Doctor of Pharmacy degree in 1994. Evelio has worked as a pharmacist at Optum Settlement Solutions for four years. Prior to Optum, Evelio managed two local hospital outpatient and ambulatory infusion pharmacies (Tampa General Hospital and All Children’s Hospital John’s Hopkins Medicine). Prior to this, Evelio spent 15 years managing a Walgreens pharmacy. Throughout his career, he has worked with worker’s compensation and managed care Pharmacy Benefit Managers (PBMs) as well as Medicare Part B and D billing to ensure care for claimants in the community. Evelio served on the Florida Medicaid Drug Utilization Review Board from 2010 to 2015 and is part Optum’s Clinical Center of Excellence.
As a pharmacist dedicated to the settlement team, Evelio reviews prescribed medications to ensure the most accurate allocation in preparation of Medicare Set-Aside submissions to CMS. He is well versed in CMS regulations and Medicare Secondary Payer (MSP) compliance. Optum leverages this expertise to identify mitigation opportunities for our clients. Mitigation opportunities are as simple as conversion to a different dosage form, to more complex cases recommending therapeutic alternatives and minimizing clinical interactions to improve outcomes for the injured worker and decreasing the client’s overall cost.
Evelio works on various products, including Medication Analysis, MSA Clinical Outreach, Peer to Peer Outreach and Nurse Progress Monitoring. The Medication Analysis consists of a comprehensive review of recent medical and pharmacy records. Following review of these records the pharmacist makes recommendations for changes of current therapy to improve clinical outcomes and reduce costs. Following delivery of a report, Evelio can offer peer to peer contact with the prescriber in order to reach agreement to decrease the cost of the injured workers prescription regimen. The MSA Clinical Outreach involves a direct outreach to the prescriber by one of our nurses on staff. Based on pharmacist recommendations, the nurse requests a more cost effective therapeutically equivalent product. Our Nurse Progress Monitoring ensures that the recommendations identified by the pharmacist and agreed upon by the prescriber are carried out so the client can realize the cost savings provided by changes agreed upon in prior outreach.
James Molloy | Senior Vice President, National Sales
James Molloy is Senior Vice President of National Sales at Optum Workers’ Comp and Auto No-fault Settlement Solutions. Jim has over 20 years of experience in the workers’ compensation industry with an extensive background in settlement and Medicare Set-Aside services. Prior to joining Optum, Jim served in sales leadership roles at MedSource, Helios (now a part of Optum), Coventry, and COMP Medical/Priority Services. He possesses a deep understanding of business-to-business sales processes, with proven success implementing sales strategies to launch new products and enter new markets. Jim is responsible for driving new business, with a keen focus on Settlement Solutions.
Melanie Carrozza, CMSP | Account Management
Melanie Carrozza is Vice President at Optum Workers Compensation and Auto Settlement Solutions. Throughout her tenure with Optum, she has lead our account management team as well as our operations team. She currently holds the role as account manager and is responsible for supporting Settlement Solutions large national clients.
In addition, Melanie works as part of the leadership team by driving strategic initiatives, overseeing program development and implementation, identifying growth opportunities, monitoring outcomes, and regularly analyzing program performance to ensure our clients get the most out of their partnership with Optum.
Melanie has focused her career in Medicare compliance since 2005 when she led the East region of Coventry’s workers’ compensation services team. Joining Optum (formally PMSI/Helios) in 2009 Melanie led our account management program and had oversight of large TPAs, carriers, and employer-based clients. In this role, she has been responsible for all phases of client management, from implementation to product development, to client retention and product training. Melanie spent three years running Optum Settlement Solutions operations, which brought a client centric focus and approach to our business, which is still embraced as our core value today.
Melanie has over seventeen years of experience in the workers’ compensation industry and has focused on the Medicare Set-Aside business for the last thirteen years. Prior to joining the company, Melanie was the Director of Sales for Coventry Workers’ Compensation Services (CWCS) overseeing sales for Nurse Case Management, Medicare Set-Asides, Durable Medical Equipment and Independent Medical Examination services.
Melanie has a Masters in Management and a B.S. in Exercise Physiology.
Steven W. Buehler | Settlement Solutions Data & Reporting, Informatics; MedicareInsights Blog
“Bueller?” Steven Buehler (with an “hl” rather than two “l”s) is part of OWCA’s Informatics group and is responsible for all of Settlement Solutions’ internal and client-facing metrics and reporting, helping ensure both the efficient day-to-day operations of Settlement Solutions and its field sales staff, and providing our clients with timely, accurate reporting on the MSA cases they have entrusted to Optum. He also manages the technical and design aspects of the MedicareInsights blog and maintains the “AskTheExperts” mailbox, making sure your questions get forwarded to the right people to respond. Other roles within Optum have included sales and account management support and Salesforce.com administration.
Prior to joining OWCA via predecessor company PMSI in 2011, his previous engagements have included seven years with AT&T Global Network Services, LLC, as an administrator and legacy global production metrics specialist, and four years with AECOM predecessor company Holmes & Narver, Inc., as a project administrative secretary on over $74 million in design-build for the Ports of Los Angeles and Long Beach. His administrative and data experience spans nearly thirty years. He is also active in social media and shares his knowledge of games, data and Quantified Self via Twitter, Facebook, LinkedIn, Mixer, and his personal blog and web site.
Steven holds a Bachelor of Arts degree with honors from Vanguard University of Southern California with additional coursework in computer networking from IBM and AT&T and in French language & culture from the Alliance Française.