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Roni S. Sitner

Roni Stutman Sitner (f/k/a Roni Stutman White) is Of Counsel to Gjerset and Lorenz. She is a seasoned senior attorney with nearly 23 years of experience in health care law and compliance, and offers a unique lens and perspective to Gjerset & Lorenz clients as she brings her in-house UnitedHealthcare insurance and managed care experience to presently counsel clients on the provider side.  Roni’s extensive experience providing counsel related to insurance and managed care extends from commercial (both self-funded and fully insured), and, for the last 14 years, the Government Program books of business (Medicaid,  Dual Special Needs Plans, and Medicare-Medicaid Plans (MMP)).

In the Medicaid Managed Care area, Roni:

  • Served as General Counsel to Medicaid Health Plans in Arizona, Colorado, Connecticut, Delaware, Florida, Kansas, Louisiana, Maryland, Missouri, New Jersey, Ohio, Rhode Island, and Tennessee
  • Served as General Counsel for Ohio Medicare-Medicaid Plans (MMP)
  • Served as General Counsel for Massachusetts Senior Care Options (SCO), a Fully Integrated Dual Special Needs Plan (FIDE)

In the Medicaid Operations area, Roni:

  • Interpreted new and amended laws and counseled the business on National Correct Coding Initiative, implementation of HIPAA administrative simplification, and implementation of ICD-10
  • Advised the business on building an overpayment recovery process for managed care health plans based upon federal recovery and False Claims Act requirements
  • Counseled health plans on state regulatory partners’ use of non-compliant codes
  • Provided guidance on lab CLIA certification and claims submission requirements
  • Advised operations teams on claim rejections vs denials, and clearinghouse issues
  • Provided interpretation and guidance of areas of the new Interoperability Rules

In the Contracts area, Roni:

  • Negotiated State Medicaid Managed Care contracts, successfully modifying provisions that were not favorable to Medicaid health plans
  • Advised Medicaid health plans on contracting for provider incentive programs such as radiology, lab, and cardiology initiatives and provider quality incentives
  • Negotiated provider Full Medicaid Payment and Guaranty agreements with providers
  • Negotiated Fiscal Intermediary contracts
  • Advised Contract Teams on specific Medicaid and duals medical and non-medical vendor contracts such as telemedicine, health information exchanges, and transportation
  • Researched, created, and negotiated supervising physician contracts for Nurse Practitioner/Physician Assistant collaborative practice agreements in various jurisdictions

In the Commercial and Government Programs Dispute Resolution areas, Roni:

  • Negotiated and settled provider issues, including those related to claims payment disputes and reimbursement policies
  • Negotiated and settled Attorneys General and other Regulatory Agency issues including government investigations and corrective actions
  • Negotiated and settled Medicaid State Fair Hearing Issues relating to Medicaid health plan member claims

In the Commercial and Government Programs Regulatory/Compliance areas, Roni:

  • Advised Medicaid and dual Managed Care Health Plans regarding new or existing laws and regulations, including those related to pharmacy, medical or reimbursement policies, and non-emergent transportation
  • Oversaw legal and compliance corrective action plans for appropriate resolution and notifications, including state Contract compliance issues such as provider directory compliance, and reporting compliance
  • Oversaw legal issues and compliance with operational implementation for State Medicaid Contract Managed Care health plan requirements
  • Interpreted and advised on Medicare and Medicaid requirements and how such requirements interact for fully integrated dual eligible health plans

In the Regulatory Relationship area, Roni:

  • Partnered with state Medicaid agencies’ legal departments for issue resolution and Corrective Action Plan resolution
  • Drafted communications on sensitive issues to Medicaid agencies, Departments of Insurance, and other regulatory agencies
  • Developed relationships with key individuals in regulatory agencies to assist in issue and dispute resolution

In the Clinical area, Roni:

  • Reviewed and advised on clinical incentive programs for legal feasibility, such as quality, coding, and HEDIS measure programs
  • Reviewed and advised on reimbursement policies for legal feasibility and statutory/regulatory interpretation, such as national and state-specific policies related to Prior Authorization and medical necessity
  • Reviewed and advised on medical policies for legal feasibility, such as state-specific policies related to gender dysphoria
  • Risk assessed situational health plan member and provider claims issues such as non-covered services, non-medically necessary services, and experimental/off-label treatments

Additionally, Roni has experience in:

  • HIPAA/Privacy issues
  • Government Program marketing requirements
  • Anti-Kickback/Stark law issues
  • False Claims/Reverse False Claims
  • Reimbursement
  • Provider Networks
  • Regulatory Agency Hearings
  • Organizational Conflicts of Interest
  • Litigation Management and Litigation

Education

  • Pennsylvania State University, B.A, 1987
  • Quinnipiac University, J.D., cum laude 1995

Professional Affiliations

  • Member, Connecticut Bar Association, Health Law Division
  • Active Member, Connecticut Bar