Francis Orejudos

Senior Manager | Moss Adams LLP

Francis has over 10 years experience in the health care industry, involving all types of managed care organizations, including HMOs, delegated IPAs, and health plans. Francis has provided operational advisory services for Medicare and Medicaid plans throughout the country specifically related to claims auditing, revenue recovery, contracting, and business process redesign. Prior to Moss Adams Francis worked with large health insurance plans and medical groups in California, with specific experience in quality assurance, performance improvement, regulatory compliance, accreditation preparation, member services, and data analytics. Specific relevant experience includes: performed Medicare and Medicaid health plan operational reviews to assess the organization’s, staffing, claims workflow, policies, procedures, quality assurance and training programs, systems, contracting, and third party vendors; managed health plan audit redesign projects to identify weaknesses in the plans’ systems, policies, procedures and guidelines; redeveloped the strategy and methodology for a health plan claims audit sampling program in order to identify immediate savings and maximize operational efficiencies; managed several audit and recovery projects for Medicare and Medicaid plans that have identified millions of dollars in overpayments, resulting in immediate savings to a large delegated IPA.


This session will describe how medical claims are processed by self-insured plans. We will explain the auditor's responsibility with auditing self-insured claims in a financial statement audit; More