Mark Abernathy

Mark Abernathy is a managing director in the Health Analytics practice at Berkeley Research Group (BRG). He has forty years of experience in the healthcare industry spanning a variety of providers, payers, and other entities, including health maintenance organizations (HMOs), preferred provider organizations (PPOs), pharmacy benefit managers (PBMs), pharmaceutical manufacturers, hospitals, state regulators, physician groups, home health agencies, ambulatory surgery centers, and outpatient diagnostic centers. He has advised clients with commercial litigation, federal investigations, bankruptcy, turnarounds, and health plan seizures. He has prepared numerous expert reports and provided testimony in litigation, arbitration, and mediation matters. Mr. Abernathy is a Certified Public Accountant (CPA), Certified in Financial Forensics (CFF), a Chartered Global Management Accountant (CGMA), and a Certified Valuation Analyst (CVA).

Mr. Abernathy has assisted clients during US Department of Justice (DOJ)/Attorney General (AG) investigations and self-disclosures. Mr. Abernathy also has assisted providers and payors defending against and preparing self-disclosures for issues such as improper settlement of cost reports, overcompensation of faculty providers, and below-market rent for office space, and he has performed calculations of ability to pay. He often is retained by regulators and appointed by state and federal courts to serve as monitor, conservator, special monitor, or examiner of health plans in violation of regulatory requirements.

Regulatory Compliance

• Assisted providers in self-disclosure for billing and coding issues, cost reporting, proper supervision requirements for interns, and other false claims and Stark Law–related issues.
• Assisted a lender of a durable medical equipment (DME) company under investigation by the Federal Bureau of Investigation.
• Assisted in a negotiated settlement with a state AG based on provider’s ability to pay.
• Assisted hospitals, DME companies, and fiscal intermediaries defend against DOJ/Office of Inspector General (OIG) investigations.
• Appointed monitor and then conservator for Alameda Alliance for Health and assumed the role of chief executive officer (CEO). He and his team effectuated a turnaround of the HMO and rebuilt and reengineered the health plan’s infrastructure due to a failed information technology conversion.
• Appointed conservator by the California Department of Corporations for MedPartners Provider Network, Inc. (MPN) and provided oversight to the orderly divestiture of MPN’s California operations. Oversight areas included claims adjudication, risk pool settlements, and practice divestiture.
• Appointed conservator by the California Department of Managed Health Care (DMHC) for Maxicare and provided oversight to daily operations, proper segregation of management services to subsidiaries, trustee reporting, and the orderly divestiture of Maxicare’s California operations.
• Worked in other oversight/monitor roles for state regulators and developed an HMO early warning system to assist regulators and health plans in identifying operational and financial problems.
• Appointed monitor by the California Department of Health Care Services (DHCS) for Borrego Health, an FQHC under DOJ investigation, and provided oversight for their corrective action plan.
• Appointed monitor by DMHC for CenCal and provided assistance and oversight for the corrective action plan to meet statutory equity requirements.
• Appointed monitor by DHCS for Gold Coast Health Plan and provided assistance and oversight for their corrective action plan.
• Assisted fiscal intermediary with disclosure of improper settlements of hospital cost reports filed over a five-year period. This involved a review of every filed cost report for every hospital during the period under investigation.
• Provided testimony and expert reports for a PBM in a Medicaid Third Party Liability dispute with state and federal AGs.

Industry Experience

• Held senior-level management positions including CEO, chief operating officer, chief financial officer, and director of development, as well as management positions such as operations analysis, internal auditor, and corporate accountant, for various healthcare entities.
• Provided advisory services to various organizations, including assisting the boards of directors of two large not-for-profit health insurance companies to understand the financial implications of disaffiliation of their organizations.
• Developed numerous intergovernmental personnel acts, negotiated managed care contracts and third-party payer agreements, and developed management services organizations and a third-party administrator.
• Developed and managed ambulatory surgery centers and outpatient diagnostic centers under management agreements.
• Developed a DME company dealing in specialty equipment and provided outsourcing billing services to other companies.
• Worked with lending institutions in the review of collectability of receivables and assisted in the subsequent collection.
• Managed DME/home health company and sold components of same to various entities.