| Litigation support services, including compliance and regulatory reviews | Assist attorneys and their healthcare clients with refunds, subpoenas, compliance and regulatory issues, civil and criminal lawsuits, arbitration and Medicare administrative appeals, as well as Department of Justice and Office of the Inspector General interviews, investigations and settlements. Perform research, case organization, data preparation and data management. Present complex issues in a clear and concise manner. Provide assurance over data submitted to regulatory-type authorities. Use medical records, disparate data sources including but not limited to electronic transaction files, electronic remittance notices, human resource files, practice management schedules and electronic files, charge masters, marketing and sales information, inventory data. Develop audit/assessment plans based on risk assessment, results of past reviews/audits, enforcement initiatives, and other factors. |
Assisted an international medical device corporation related to nine criminal and civil allegations for one subsidiary on financial credit matters, false claim and medical record documentation issues. Interfaced directly with counsel, senior client members and board members, Assistant United States Attorneys and professionals from Department of Justice, Washington, DC. Designed a series of clinical and billing models based upon reconstruction of disparate data sets with varying assumptions and scenarios that was used in potential error calculations.
Assisted legal counsel to a third party administrator in litigation concerning their administration services contract with a health plan sponsor. The sponsor alleged, based upon the findings of several consulting firms, that the TPA breached its fiduciary responsibility as the administrator for certain plans. In breaching this responsibility, they alleged that the TPA 1) Inappropriately paid claims for medical services; 2) Failed to accurately maintain membership information, including coverage parameters that impact payment; and 3) Inappropriately charged for administrative services. One of the medical service areas in dispute was the claims processing, subrogation and Medicare as a secondary payer requirements and information associated with specific claims for trauma and CVA/stroke patients at long term acute care hospitals. Conducted data analysis to both refute the sponsor’s audit findings and to undermine the methodology used to calculate the overpayments and an analytical review to determine any potential exposure that may be associated with the allegations. Supported expert witness testimony on behalf of the client. Assisted legal counsel in litigation for a third-party administrator concerning claims payment accuracy and review procedures. The TPA faced allegations that it had inappropriately paid numerous claims. Assisted in analyzing and defending against plaintiffs’ allegations of payer processing inefficiencies and process issues. Analyzed the methodology employed in the review and found it to be inaccurate and misleading. Utilized a combination of First Data Bank© datasets, Joint Commission standards, American Society of Health-System Pharmacists’ literature, client claim and inventory data and desk-based and onsite-observation based review protocols to assist counsel with an investigation of a pharmacy/durable medical equipment supplier for several alleged issues. Data from these various sources was analyzed to detect, benchmark and quantify exposure related to controlled substance fill rates, submission rates of incorrect National Drug Codes, claim reversal rates, alleged kickbacks, fee splitting arrangements and quality control/medication inventory management issues. Assisted legal counsel on a potential Stark/fee splitting/reassignment matter involving two physician groups who were interested in developing a business arrangement with a diagnostic provider. Assisted legal counsel on alleged Stark, purchased test, interpretation rules and contract matters associated with an IDTF, including issues on fee splitting. Assisted legal counsel and provided clinical coding, analytical and corrective action services/support to a physician pathology group and four distinct hospital network providers on generating voluntary refunds to Medicare contractors regarding purchased tests and various Medicare-regulation based issues. Supported an FBI agent on a criminal kickback case involving an influential physician who was a member of the Medicare Carrier Advisory Council and a home health agency. Working in a collaborative environment with the client and legal counsel, assisted multiple national corporations and physician practice groups on the design, development and implementation of corporate compliance programs. Investigated issues on claims billing, potential false claims, Stark regulations, physician contracts and HIPPA. Reviewed physician salary and contract terms and compared them to various data sets to provide comparative guidance on salary and business terms. Developed system based reports and system-embedded rules to assist in monitoring and evaluation of specific issues. Performed periodic testing for compliance effectiveness and potential identification of issues. Several of these entities were negotiating or already under Corporate Integrity Agreements. Assisted legal counsel in the defense of an alleged improper health care billing practices for various health care providers, physician groups and suppliers through utilizing data analysis to examine practices of payment, billing and adjudication issues and performing statistical sampling to quantify alleged billing irregularities. Participated in numerous healthcare litigation projects on claims processing topics ranging from pre-existing conditions, prompt payment, industry “standards” for claims processing “correct coding” software, to the processing of prescription drug payments and reimbursement for alternative medicine providers. For several regulatory matters, investigated issues identified by state insurance regulatory agencies, including potential fraudulent avoidance of paying of legitimate health care expenses and/or incurring liabilities, manipulating claims received date to modify timeliness metrics compliance and manipulating claims adjustments to hide claims system irregularities, understatement of claims expenses and interest penalties. |
| Fraud and abuse detection | Create software code and methods for detecting and processing data driven cases. Create "fraud task specifications" to compile a master database for documentation, record management and cross-referencing. Work experience in detection of employee fraud for health plans, for Medicare contractors and have work experience on procurement fraud issues includes matters such as defective/inaccurate pricing, contract fraud, product substitution, defective products, false claims, kickbacks, grant fraud, labor mischarging, ethics and conflict of interest violations. Designed, developed, implemented and validated analytical methods to detect health care fraud and differentiate it from abuse in both Medicare Part B and Medicare Part A programs within Florida. Developed methods to detect Medicaid fraud in a variety of states using various sources of data. Provision of training to internal audit and other organizations concerning data analysis and computer-assisted auditing techniques. Fraud risk management. |
Using disparate data sources, detected several cases involving improper physician ownership and referral patterns. Provided analytical support to case investigators for referral to law enforcement and corrective action. Performed consultative services for Centers for Medicare & Medicaid Services, Central Office for the Medicare Integrity Program group’s initial design, scope of work and implementation of the Program Safeguard Contractor initiatives. Have also worked on Medicare contractor internal controls reviews (SAS 70 Type I and II), Medicare contractor’s medical review projects and cost report audits. In one case, created fraud detection queries and analyzed a managed care cost payer for appropriate implementation of Medicare coverage policies and use of appropriate claims processing requirements defined under Operational Policy Letters. Created statistical samples for medical record review. Detected overpayment amounts and worked with the cost accounting team for appropriate apportionment and calculation of overpayment amounts. For various litigation matters, assessed and evaluated Medicare contractors for claims processing, financial allocation and coverage issues. Worked with an international firm assisting them in fraud detection methodologies based on their claims processing procedures and available information. Participated in a due diligence survey of multiple pharmaceutical providers for fraud in billing patterns. The outcome of a profiled provider study documenting the activity of 360 medical personnel historically linked to fraud in Florida who billed the carrier for $285,684,455 and were paid over 91 million in a 2.25 year time period. Analyzed a wide variety of diverse data to define attributes that potentially could be monitored in a payment safeguard algorithm. A multistate clinical laboratory scam involving 2,683 beneficiaries and 16 clinical laboratories. Resulted in a temporary restraining order seizing more than $6 million in assets. Working with an F.B.I.--provided data book encrypted in code, used claims and eligibility information to identify patients and physicians. Provided analytical reports and compiled cross referencing information to the F.B.I. agent who was able to use them to interview individuals. Provided investigative and provider registration staff with supporting documentation that depicted 316 distinct geographic locations (invalid addresses) during a six month period. These locations involved 716 Medicare provider numbers. The first case, Med EO Diagnostic, used the names of deceased patients and a rented mailbox in West Dade, Florida. This case was referenced in a Miami Herald article on August 14, 1994. An ongoing criminal case in Miami involving over 60 medical entities and 3 billing companies was identified. On behalf of 28 provider numbers, this network billed more than $141 million and was paid in excess of $41 million over a thirty month period. The first data analysis referral to HHS OIG documenting a massive beneficiary ping-pong scheme involved 290 beneficiaries and 165 performing providers with total billings in excess of $200 million for 18 months. If one considers referring and billing amounts for this network, financial totals exceed $500 million. More than 90% of beneficiaries identified were extensively involved in the "HCFA R16" issue and 80% of the beneficiaries were dual eligible. This case was mentioned in Dr. Malcolm Sparrow’s Book, License to Steal (Westview Press, 1996). Various "Follow the Money" studies, utilizing analytical techniques from the fields of statistics and operations research, provided foundational results for future program safeguard development, medical policy revisions and other studies. Trending of diagnosis codes detected two clinical labs responsible for a false yaws epidemic in South Florida. Suspension of these two providers saved 3 million dollars. Collaborated with a research team at Los Alamos National Laboratory who were working on a HCFA contract for the Medicare Transaction System to develop proactive payment edits and neural network methods for fraud detection. Supervised, performed research and operationalized “red flags” for forensic tests; reviewed “red flag” development and testing for relevancy, accuracy and consistency. Have utilized a broad range of tools for forensic testing techniques. Provided financial and investigatory analysis to detect health care fraud in disparate data sources, including claims, contractual and public domain data. Worked with a physician to generate and document new fraud queries and approaches for specific clients based upon available data and potential coding issues identified in part by data driven processes and interviews. All assignments required extensive analysis, problem definition and planning, and coordination with the client (commercial payers) and with internal team members. Acted as a factual witness for the United States government, testifying on data findings and approaches/methodologies used to detect fraud and differentiate fraud from abusive or normal industry practice patterns. Subject matter expert in advising on a government project for detecting fraud and abuse in pharmacy and in drafting a request for proposal and scope of work. |
| Expert witness | An accurate and straightforward presentation of our opinions on the core facts and relevant issues; presented with integrity and objectivity.
Subject matter expertise during actual testimony or for deposition. |
Selected as an expert witness by external counsel for a coding matter related to Medicare’s Inpatient Rehabilitation Classification.
Selected as an expert witness regarding a qui tam case against an international firm (matter ongoing). |
| Health care data analytics and statistics | Specially tailored, creative, insightful, and defensible data-driven solutions from vast and disparate sources. Data can be transformed into information and this information leads to solutions/insight.
Extensive expertise in data mining and analysis, statistics, healthcare information systems and technology, clinical guidelines, Federal and State health program billing, database developmental methodologies and life cycles (e.g., information data modeling; database standardization processes; enterprise data management principles and strategies, software requirements analysis) and claims processing/management (including Fiscal Intermediary Shared System, VIPS/VMS, Multi Carrier System, Common Working File Systems, Facets®). Helped clients and their counsel identify, acquire, organize and manage the client’s data to support counsel in responding to discovery requests. Can efficiently and effectively communicate with technical client staff and counsel to help take steps to maximize institutional knowledge while minimizing inconvenience and misunderstanding. Have built repositories of clients’ data “offline” from its current and legacy transactional systems that have been used to prepare data productions for counsel to share with other parties. Once the data has been identified and assimilated, can use this data to conduct critical, in-depth data analysis to assist the client and outside counsel in defending against an investigation or litigation and in quantifying potential damage exposure scenarios. Have also combined clients’ data with other publicly available industry data to help maximize the productivity of our data analysis and findings, thereby providing counsel with meaningful, useful, and intelligible information throughout the investigation or litigation lifecycle including: initial investigation, discovery, expert testimony, damages quantification/rebuttal, settlement negotiations, and trial. Using various methods, generate statistical samples that were customized to the data and issues. Perform analysis of data to identify specific types of exceptions. Assist in the provision of specific information to assist management in decision-making. Analyze data to assist in resolving (complex) reconciliation issues Assess, map, improve and convert data to support business processes and applications. Plan and test for complete and accurate conversion, including if needed data cleansing and/or enrichment of data from legacy systems to a new or existing system. Analyze data within a particular database or across multiple systems to support and enhance management decisions (sampling, sorting, calculation, modeling, reconciliation and/or verification). Define records-management policies and procedures to provide the company with adequate information lifecycle management. Generate graphical and numerical descriptive methods Interpret testing and validation (or lack of) procedures for counsel and client Generate, formulate and utilize inferential statistics and other advanced analytical tools such as forecasting and time series, network analysis, sensitivity analysis and linear programming, behavior profiling, cash flow analysis and other quantitative business methods, cost accounting, calculus, market segmentation/marketing research techniques and clinical medical knowledge to process claims data and public information to detect fraud. Use financial models to detect abnormalities in typical business practices on a macro level. Analyze historical income annual and monthly cash flows and expenditure. Examine business records and surveys for aberrancies. Extensive experience in innovative situations requiring analytical, interpretative and constructive thinking. Have proven ability to transfer concepts and ideas from a wide variety of fields to solve specific problems. In-depth knowledge in research and public information sources and assessing its relevance to health care issues and potential investigative support. |
|
| Data analysis/business transactions including budgets, contracting, transfer of ownership, acquisitions, feasibility and marketing studies | Research and prepare feasibility study
Assist ancillary providers with changes in ownership, addressing all required contracting, compliance and licensure issues to ensure a seamless transition with insurance payers Generate pricing estimates Perform due diligence for investment banking groups Generate “quick” fair market value template and created estimates for rental space in physician offices Generate budget estimations for the U.S. Congress for proposed services Conduct data analysis and performed limited surveys to assist a hospital electronic health record software firm evaluate pricing and marketing characteristics for community and critical access hospitals. Prepare physician office criteria for evaluating various vendor’s products on practice management and electronic health records |
Budget estimation of Medicare digital mammography coverage costs based upon multiple disparate data sources.
Cost estimation based upon time and work study for separate coverage of glucose monitoring activities with skilled and assisted living patient groups. Working for a physician group, evaluated for a travel clinic idea in Washington DC Researched and prepared multifaceted feasibility study for pediatric patients with chronic illnesses. Performed a limited evaluation of a network of managed care companies for an investment firm to address subscriber eligibility, medical management and claims processing issues. The work was accomplished through applying focused statistical methods and data analysis. Used a combination of managed care claims data, InterQual® and Millman and Robertson clinical benchmarking criteria, Acute Physiology And Chronic Health Evaluation (APACHE) and Healthcare Effectiveness Data and Information Set (HEDIS®) outcomes measurement data, evidence based national guidelines and disease prevalence data from the public agencies such as the Centers for Disease Control and Prevention to evaluate the companies for various issues. Performed due diligence for an investment group interested in the purchase of a large durable medical equipment supplier. The group was concerned about the accounts receivable balance and underlying medical record documentation and contracts. Performed five assessments for investment firms interested in offering initial public offerings in the biotechnology or diagnostics area. |
| Data analysis/billing | Calculate potential overpayment amounts
All aspects of revenue cycle management Used electronic 835 information to facilitate the posting of payments for a large number of accounts by performing a join by patient account number and date of service After identifying selected patient accounts in a client’s data warehouse, used electronic 835 and 837 information to obtain internal claim numbers that were used to reduce the overpayment amount in settlement negotiations. Charge master reviews. Identify missing revenue, apply appropriate pricing, and ensure integrity for each cost center. Review codes assigned to hospital charges. Verify that all current services are listed in the correct department. Address missing charges. |
Worked with multiple clients in calculating overpayment/refund amounts
Worked with claim and medical record information to assess and investigate an alleged incident to issue at a rural family practice clinic; based on NPI number, identified a very small number of medical records and transactions at issue Multiple projects on the revenue cycle and process flow improvements, charge master reviews, identifying IT enhancements, patient credits Worked denial, aged A/R, collections and appeals projects for various provider types; e.g., assessed the clinical and financial denial management process, identified payer and provider contractual and claims processing issues to address the denial activity; evaluate the internal collections process for compliance and effectiveness; evaluate for bringing collections internally from external entity; provide business intelligence based on data analysis and benchmarking. |
| Electronic health record | Provide a focused and timely solution to your business, legal or regulatory matter.
Experienced in the planning, design, migration, analysis and operation of electronic health record systems, including all aspects of electronic record system management (for example, content, documents, forms and process management) and legal electronic health record issues. Understand the issues created by an ever-expanding amount of electronic patient information and the resulting need to define data elements, metadata, digitized documents and reports and paper documents that comprise the legal electronic health record Understand that legal health records that are too narrowly-defined and do not adhere to a sound document retention policy can create legal risk. Help clients define and create legal electronic health record definitions that work for their organization. Whether the issue is defining the legal electronic health record for responding to routine information requests or subpoenas, we can provide strategic assistance. Apply my knowledge of all aspects of the process -- from policy and procedure development to data integrity testing. Electronic health record/Electronic document management system risk reduction and data integrity reviews. |
Various consulting projects on record retention, electronic prescribing and electronic signatures, standards for “late entry” and making record addendums.
Worked with several clients on their [internal] definitions of what is a legal health record, trying to identify what is administrative and what is clinical/part of the record. Have knowledge of tools that can be used, including some in the public domain that can help identify and gather data sources for the record. Supported a national corporation in the planning, selection and implementation of an electronic health record system. Project work included assisting internal clinicians, information technology personnel and compliance staff in the design of medical record form issues, policies and procedures that addressed accuracy, authorship, authentication and audit trails of the legal electronic health record. Additionally, our team addressed operational issues such as redundancy during the transition from paper to electronic records. Facilitated internal dialogue among multiple stakeholders to define the legal health record in the electronic environment, to ensure it adhered to the applicable rules of evidence, to understand limitations of the client’s current legal health record, and to delineate the difference between disclosure of the business record versus discoverability of data elements and reports. Assisted in designing, developing, testing and reporting a proprietary electronic clinical laboratory results reporting system for a national clinical laboratory corporation. Worked with a multidisciplinary group, including clinicians, information technology personnel, compliance staff and operations professionals. As a component of the testing, we evaluated control, access, entry timing, dating and authentication, privacy, security, data integrity and retention issues. In addition, we performed data mining to test for both legal functionality and data quality measurement. This work was a component of an investigation and compliance corrective action project associated with an OIG/FBI subpoena and Medicare suspension. Analysis of metadata for overrides on drug interactions, allergies or other clinical notifications Litigation experience involving electronic health record software and medical transcription issues. Legal health record definition development, including leading multifunctional and diverse teams in meetings and discussion. Consulted on evaluation of medical informatics tools to enhance a hospital organization’s enterprise management initiative/electronic document management system project. |
| Computer assisted coding | Evaluation of products for outpatient clinic and billing service.
Evaluation of internal processes, infrastructure and work flows to assist in productivity improvements and optimize the technology |
Various consulting projects
[Co-chair of national work group on this topic; AHIMA facilitator, co-author, cited in For the Record Interview to be published in September 2009] |
| Database design and medical record abstracting | Database development and medical record abstracting for various projects, including research and registries.
Information for litigation, strategic or risk management/compliance matters. Experience with database development, planning and producing reports; identifying and collecting data for input and performing validity checks for consistency, financial and security purposes. |
Designed a 140+ data element tool to gather information from the medical record for a pediatric hospice/palliative care nonprofit collaboration. Abstracted outpatient, inpatient, rehabilitative and hospice medical record information into the database
Designed a long term care pharmacy/medical record database; abstracted hybrid patient information and loaded electronic information into the database Designed and developed tools for hospital short day admissions, imaging and durable medical equipment billing and coding reviews. Developed billing compliance database for durable medical equipment and a compliance risk assessment grid to support legal counsel’s efforts in creating and implementing an internal compliance plan for their durable medical equipment and pharmacy business segments. |
| Pharmaceutical | Detected drug diversion using adhoc and system generated reports and inventory/medication management reports
AWP pricing Investigational drugs Off-label use in pediatric patients Off label use in psychiatric patients Selection and testing of pharmacy systems, CPOE, prime vendor Standing orders and order sets in the emergency room Product Liability Pharmacy compliance |
Working under legal counsel, assisted a group of three pharmaceutical providers that served long-term care and assisted-living facilities. We tested and implemented a computerized order entry system that resulted in the generation of associated electronic health records. Analyzed and assessed the compliance and financial ramifications of data integration, data accuracy and data integrity issues as they operated in a hybrid record environment. Performed limited review and analysis on patient samples using system access, authentication, “audit trail functions” and ad hoc reporting features. Additionally, we utilized system data, patient profiles, patient contraindication profiles, inventory information, medication administration reports and claims generated in order to assess prescription fills, duplicate orders and medication errors.
* Performed operational testing and reviewed programming code/logic and databases to assess purchasing and inventory management issues including inventory shrink and/or drug/product diversion for several pharmaceutical and life science clients. Compared and contrasted this information with the claims submission cycle(s), reimbursement amounts and rebate/refund amounts. In one case, detected programming logic in subroutines that generated additional inappropriate discounts for drugs and supplies. In another case, detected inappropriate exclusion of specific brand name drugs that impacted a variety of issues, including sales and pricing calculations. In both cases, financial amounts were calculated to be used by legal counsel for disclosure. Assisted legal counsel on investigative matters for a large pharmaceutical company that involved identification of marketing, financial and sales data related to specific drugs identified in a criminal subpoena. As a component of this work, analyzed marketing, contract and internal information to assess business practices and compliance. Compliance review and creation of policies and procedures to address issues relating to the nursing staff printing medication administration records on demand. Compiled various documents for diverse consulting projects such as medications that cannot be sent through the pneumatic tube system, policies and procedures for Pyxis overrides, best practices on how to inform Medicare observation patients that certain self-administered meds will not be covered by Medicare during stay and evaluating assistance for these patients in submitting these charges to Medicare Part D plans. Performed medication reconciliation for hospital-based and long term (closed) pharmacies. Conducted compliance durable medical equipment and pharmacy services billing reviews, with various components such as medical coverage, billing, coding, documentation and regulatory elements for different groups of sample patient files from Medicare, Medicaid and TRICARE. Co-inventor of two international and US patents; both of which were purchased by a large pharmaceutical firm for use with Premarin® (Patent #5,550,029 dated August 27, 1996 filed under the name Simpkins, et al and Patent #5,554,601 dated September 10, 1996 filed under the name Simpkins, et al) |
| Legal Electronic Health Record, Disclosure and e-Discovery | Provide insightful solutions to the specific matter.
Possess experience in electronic discovery, including tailoring it for the compliance issues specific to a healthcare organization and ensuring that health information remains confidential. Just like the medical conditions that electronic health records track, no two e-discovery situations are exactly the same. Legal counsel, HIM and risk management professionals need practical, tailored guidance for navigating the e-discovery process. Provide assistance to legal counsel, HIM and risk management professionals in simplifying their approach to e-discovery requests. In litigation, can identify the potential custodians of electronically stored information, classify the location, type and format of the data, orchestrate the timing of the collection, and evaluate the rationale for why the data is being collected. Assess an organization’s current electronically stored information model, evaluating electronic health record for accuracy and completeness, helping health information management professionals manage the enterprise-wide components of electronic health records. |
Assisted legal counsel by providing strategic, analytic and technical expertise in e-discovery issues associated with hospitals, physicians and third party payers as it related to multiple class action lawsuits on various medical devices. Working with counsel, drafted e-discovery production and third party subpoena requests. The scope of the project addressed access, location, retention, and use of information, data, metadata and records created or maintained in electronic media within various health care settings. . The project also involved generating coding scenarios for inpatient and outpatient billing of implantable devices. This included but was not limited to determining when a replacement device was subject to the special billing rules, reporting the correct modifier, condition code, and adjusted charge for devices, analyzing payment and addressing the documentation for the cost of replacement devices. |
| Clinical coding/medical auditing | Deliverables vary based on the project - have prepared oral presentations, reports, tables; presented draft exhibits shared on GoToMeeting
Determine usual and customary charges on medical bills to introduce reasonable expenses of necessary medical care into evidence. Experience in medical terminology and various coding protocols/tools including AMA CPT Codes, ICD-9 coding, APCs, OASIS, RUGs, CMS Hierarchical Condition Categories (HCC), DRGs, MS-DRGs. Familiar with ICD-10, LOINC, Sno-Med, HL-7 and various operational standards for the electronic environment (e.g., ANSI, CCHIT). Experienced in numerous clinical coding tools including encoders, morbidity adjustment protocols (e.g., John Hopkins' APC), severity adjusted protocols. |
Assisted legal counsel relating to a private payer contractual dispute on the appropriateness of outpatient rehabilitation coding, coding bundling rules and the use of CPT modifier “59”, “Distinct Procedural Service”.
Medical record review/risk assessment with charge master tracing and financial reconciliation for a Texas pediatric teaching hospital on psychological testing services provided in an outpatient setting by non-staff clinicians. Generated recommendations for in-house and external counsel and senior clinicians regarding compliance, data quality and financial data set transaction information. Generated potential risk exposure for specific issues. Experienced with multiple coding and medical utilization issues, including admittance criteria and Joint Commission standards, for long term acute care hospitals. Experience focuses on stroke/CVA, trauma and ventilator dependent patient cohorts, including clinical coding of ventilator and wound debridement patients (DRG 207, DRG 97 coding), critical care polyneuropathy (ICD-9 code 357.82) admission for treatment of infection (e.g., sepsis) and coding of traumatic subarachnoid hemorrhage patients with neurological effects. Performed data analysis and medical documentation review to detect and analyze data anomalies of various aspects of evaluation and management coding (duplicate claims, upcoming, improper consultations, multiple dates of service emergency department visits, critical care coding, established versus new patient rules, CPT code modifier utilization). Clients include a Medicare Fee for Service contractor, Medicaid fiscal agents; one Medicare cost based managed care plan and two private payer plans. Familiar with the 1995, 1997 and 2000 Evaluation and Management documentation guidelines as well as other payer documentation guidelines (e.g., TrailBlazers). Performed extensive analysis with Medicaid data and billing requirements for ESRD, clinical laboratory services, pharmaceutical services and managed care. Led, managed and/or participated in coding integrity related projects, including but not limited to specialty specific coding education (1) reviews, (2) research (3) education and (4) financial analysis. |
| Training | Provide training programs, seminars, and presentations for professional and trade organizations, and guest lectures at universities.
Speaker and author for very diverse audiences. |
Have designed and delivered trainings on issues ranging from e-discovery, fraud and abuse in electronic medical records and claims data elements that have been attended by internal employees and hundreds of external professionals. See resume for listing.
Two years experience as a fulltime educator and instructor. |