David Giles is a Senior Consultant at Gorman Health Group (GHG). In this role, he has designed and developed Medicare Advantage (MA) and Medicare-Medicaid provider networks, as well as worked with clients to develop strategies that address provider-related MA compliance problems and issues that impact Star Ratings. David brings GHG clients more than 25 years of healthcare experience encompassing new market development, management, operations, and consulting for Medicare, Medicaid, TRICARE, commercial, and employer health plans. His expertise in healthcare reimbursement and provider contracting has been used by clients to develop and model reimbursement strategies; design, evaluate, and optimize provider networks; and analyze new market opportunities.
Major projects have included reengineering provider networks and reimbursement to meet the challenges of the evolving MA revenue climate and to optimize the use of more cost-effective providers, particularly hospital providers. This also included review and modification of existing provider pay-for-performance and risk sharing arrangements to better align financial arrangements with health plan goals.
Before he joined GHG, David served as a health plan manager for commercial and Medicare lines of business for two national health plans, two start-up Health Maintenance Organizations (HMOs), and as a consultant to health plans, employers, hospital systems, and physician groups. His clients included the Louisiana State Employees Health Plan for whom he designed the standardized reimbursement system used statewide, a Regional Preferred Provider Organization (RPPO) developing a multi-state provider network, and a large national employer who developed an integrated employer clinic and medical home.
David is also a database developer and has served as an expert witness on health care reimbursement. He is a graduate of the University of Pennsylvania and is based in Raleigh, North Carolina.