Provides Opinion & Testimony In:
Quality Assurance in Medical Standards, Quality Assurance Medical Standards Medical Billing Utilization Review, Board Certified Medical Billing, Insurance Claims Medical Standards of Care, Quality Assurance Medical Standards Medical Billing Coding, Medical Billing, Quality Assurance Medical Standards Medical Billing Managed Care HMO, Medical Over Billing Fraudulent Billing Practices, Quality Assurance Medical Standards Medical Billing, CPT Coding
Commonwealth of Massachusetts, 1982
State of New York, 1982
State of New Hampshire, 2004
Public Health/General Preventive Medicine, 1996
Quality Assurance/Utilization Review, 1987
Medical Management, 1997
Harvard School Of Public Health, Boston, MA
S.M. in Health Services Administration, June 1986
Department of Health Policy and Management, concentration in management curriculum. Tutorial in strategic planning.
Tufts University School Of Medicine, Boston, MA
M.D., May 1981
Activities: Photography and Editorial Staff, 1981 Yearbook.
Contributing columnist, “Blunt Dissection”, Tufts Medical School student publication.
Harvard College, Cambridge, MA
A.B., June 1977, cum laude Biochemical Sciences.
Awards: Edwards Whitaker Scholarship for “outstanding scholastic ability and intellectual promise”, 1974; Harvard College Scholarships “in recognition of academic achievement of the highest distinction”, 1975 and 1976.
Activities: WHRB-FM News Reporter, Writer, and Announcer. Letterman, Varsity Fencing.
1989 to Present
Representative Consulting Engagements
A Life Insurance Company Boston, MA
Medical Director, UniCare Claim Policy and Regulatory Affairs; Medical Consultant to New Product Research and Development section of Indemnity and Managed Health division, developing National Transplant Network PPO nationwide, as well as enhancing automated clinical intelligence of claims processing function, and reviewing cases for Claims Support Services. Member, ERISA Appeal Committee.
Boston Clinical Trials
Primary Investigator for several clinical trials involving chronic pain, insomnia and constipation drugs.
Boston Clinical Research Center/Med trial Boston
Sub-Investigator for numerous clinical trials involving migraine headache drugs.
Anthem/Blue Cross Of Connecticut, North Haven, CT
Physician Reviewer/Medical Consultant, conducting physician-to-physician discussions of patient care for pre-admission certification and continued stay, as well as retrospective chart reviews to determine medical necessity/appropriateness of care.
Expert Witness and Litigation Consultant in successfully concluded and ongoing medical malpractice and criminal cases as authority on quality assurance in medical care and medical billing. Clients have included physicians, insurance companies, the U.S. Department of Labor (in case involving propriety of expenditure of union health benefit funds), and the U.S. Department of Justice (in billing fraud case).
Healthcare Television Production, Dearborn, MI
On air medical correspondent for syndicated consumer-oriented health care television program.
Medical Review, Nashville, TN
Review physician supporting nurse reviewers with clinical expertise, and physician-to-physician review for healthcare utilization and claims management.
A Clinical Software System, Brookline, MA
Coordinator and lead clinical designer of team which developed clinical software system to manage duration of short and intermediate term disability for two sets of the most frequently occurring injuries and conditions in employed populations. Review physician for Medical Intelligence Review Service, supporting automated Medical Appropriateness Protocols implementation.
9) Peer Review Analysis, Malden/Boston, MA
Senior Review Physician, conducting physician-to-physician discussions of patient care for pre-admission certification and continued stay, as well as retrospective chart reviews to determine medical necessity.
Medical Director for State of Connecticut Drug Utilization Review Program.
A Private Healthcare System, Waltham, MA
Co-developer of quantitative method for collection and analysis of RFP response data for Designated Centers selective network project.
A Long-Term Care Group, Eden Prairie, MN
Provided Medical Director services that focused on quality assurance in LTCG’s claims and underwriting operations, including claim and medical record reviews and assessment of individual underwriting risks.
Serono Laboratories, Inc., Norwell, MA
Member of team preparing and writing New Drug Application (NDA) for submission to the United States Food and Drug Administration (FDA).
A Consulting Team, Boston, MA
Member of team consulting to a large, state-wide New England health insurer evaluating prospects/possibilities of designing, creating and implementing an MSO for its own as well as external use.
Response Healthcare Information Management, East Greenwich, RI
Consultant in the conceptualization and design of health status and health risk assessment instruments for use in Medicare populations to project and manage utilization.
HCIA/Sachs; Solucient, Waltham, MA
Develop, maintain and market physician profiling and claims auditing software.
Mosby Consumer Health, Boston, MA
Review, edit and write content for new media healthcare publisher.
Journal of Clinical Outcomes Management, Philadelphia, PA
Peer reviewer of articles submitted for publication.
Clinical Information Advantages, Inc., Waltham, MA
Knowledge Engineer for voice recognition automated radiology dictation/transcription system.
June 1997 to Present
A Life and Health Insurance Company, Piscataway, NJ
Associate/Acting Medical Director. Responsibilities include:
Supervising pre-certification, concurrent review and case management nursing staff;
Credentialing network providers;
Coordinating activities of the Physician Advisory Committee;
Supporting Quality Improvement Committee activities.
1997 – 2000
Optimed Physician Review, Lexington, MA
Chief Medical Officer. Responsibilities included:
Recruiting, training and managing multi-specialty staff of review physicians;
Monitoring and assuring compliance with legislative and regulatory initiatives on utilization management nationwide;
Establishing policies and procedures for review service;
Analyzing and reporting review performance to clients;
Marketing review service and managing client relationships;
Performing pre-admission, concurrent and retrospective review.
June 1994 to August 2006
Cosmetice Laser Surgery, Burlington, MA
Staff Physician/Director of Training and Clinical Quality
Direct patient treatment and education;
Design and implementation of clinical quality assurance and physician training programs.
1988 – 1994
GMIS, Malvern, PA
Associate Medical Director. Responsibilities included:
Clinical design of ClaimCheck, the first fully automated cost containment system for healthcare;
Maintenance of clinical integrity of AutoCoder, software computerizing health claims encoding;
Marketing and medical representation of GMIS products;
Development of Provider Insight for clinical profiling system.
Health Data Institute, Lexington, MA
Senior Scientist. Responsibilities included:
Analytic consulting – provided clinical direction to analysts writing reports evaluating health claims data to identify cost containment strategies preserving quality of care;
Physician contributor to Department of Health and Human Services, Office of the Inspector General National DRG Validation Study, and Commonwealth of Massachusetts Hospital Rate Setting
Commission project evaluating hospital case-mix statewide;
Medical review – contributed to the design of the Optimed pretreatment review and Workability disability management software systems, and functioned as review physician, negotiating with physicians nationwide to achieve agreement on lengths of hospital stays, duration of disabilities, and proposed treatment plans involving numerous specialties;
Computer systems – designed and enhanced AMS, an automated claims editing system for evaluation of data accuracy, medical validity and internal consistency of health care claims.
Lahey Clinic, Burlington, MA
Radiology Resident. Responsibilities included:
Performance and interpretation of various modalities of diagnostic imaging studies;
Seminar presentation “Villous Tumors of the Duodenum”.
Bridgeport Community Health Center, Bridgeport, CT
Medical Director, as Commissioned Officer in the United States Public Health Service National Health Service Corps
Delivery of primary medical care to broad spectrum indigent patient population, from infants to elderly at inner city walk-in setting;
Planning and implementation of health education, promotion and disease prevention programs;
Supervision and quality assurance of all clinical personnel and healthcare delivery activities.
Framingham Union Hospital, Framingham, MA
Flexible Internship included practice of Pediatrics, Internal Medicine, Surgery, Emergency Medicine and Intensive Care.
Available upon request.
Available upon request.
Memberships: National Association of Physician Broadcasters
American College of Physician Executives
Licensed Insurance Advisor, Commonwealth of Massachusetts, 1998.