Medicare Medical Coding Coverage Expert Witness

Provides Opinion & Testimony In:

Medicare, Medicaid, Payer Coverage, Reimbursement, Medical Audit, Medical Policy, Medical Coding, Medical Billing

EMPLOYMENT

From July 2014 – Present
Physician Consultant

Expert provides consultative services in medical policy, compliance, audit, Medicare rules and regulations, billing, documentation and ICD-10 for government and private payers, industry and providers. This includes Medical policy development, clinical trials design and other medical billing compliance, documentation compliance, medical device and drug marketing, coverage expertise, ICD-10 training, medical claims processing automation, and medical claims data analysis and audit. Expert also has extensive experience consulting and testifying for the United States Department of Justice and private attorneys in Medicare criminal and civil fraud trials and other civil proceedings.

From October 2017 – July 2019
Consulting Contractor
Medical Director, UPIC MW, AdvanceMed

Expert consulted as the Contractor Medical Director for the Midwest Unified Program Integrity Contractor (UPIC). His duties involved providing insight and expertise for Medicare and Medicaid claims review decisions and national coverage payment issues, interacting with other Medicare and Medicaid Medical Directors and physician groups, beneficiary organizations, and congressional offices. Expert assists law enforcement and the Department of Justice in fraud investigations and provides expert testimony at hearings and trial.

From December 2014 – October 2016
Consulting Medical DirectorPricewaterhouseCoopers

Working through PwC, provided leadership in developing medical policy for large multi-state and mid-size commercial health plans. Duties involved claims data analysis, medical policy development, medical policy Web site development, and claims edit implementation.

From December 2010 – June 2011,
Medical Director
July 2014 – present
Emerson Consultants, Inc.

Provides expert medical consultation on payer coverage requirements for the medical device industry.
Reviews new technologies to propose clinical study design to ensure post-approval coverage;
Develops strategies to seek specific device coverage or overturn non-coverage decisions by government and commercial payers;
Reviews clinical data to make recommendations to strengthen coverage and payment positions.

From December, 2009 – June, 2011
Physician Consultant, Meade & Roach LLP
From July 2014 – Present
and Aegis Compliance & Ethics Center, LLP

Duties and Responsibilities:
Lead physician consultant for matters relating to hospital billing compliance, clinical drug and medical device trials, and investigational device (IDE) trials;
Provides expert opinion on Medicare rules and regulations, provider documentation and compliance, and third party payer medical review and coverage.

From September, 2001- Present
Physician Consultant, Expert Witness
United States Department of Justice
Duties and Responsibilities:
Assists Assistant U.S. Attorneys in Illinois, Wisconsin, Minnesota, Louisiana, Georgia, Tennessee, Florida, Maryland, and Washington, DC in Medicare fraud case development and record/case review
Serves as expert witness in Medicare fraud trials involving medical devices, institutional and physician services.

From July, 2011 – June, 2014
Chief Medical Officer, Performant Recovery, Performant Financial Corporation

Served as Chief Medical Officer and Contractor Medical Director (CMD) for Performant Recovery, the Recovery Auditor (RA) for Region A, which encompasses the northeastern United States.
Created the New Issue Development team that develops automated, semi-automated, and complex medical review concepts;
Directed development of medical review guidelines for complex review of medical necessity for inpatient stays and DRG validation;
Provided direction for data analysis for review of claims data billing aberrancies;
Participated in and directed the claims denial discussions process with physicians;
Created the team that administers Administrative Law Judge Hearings and trained physicians in ALJ hearing testimony;
Provided medical direction for all other healthcare services business development with commercial payers. Responsible for securing contracts with three large commercial payers.

From May, 2010 – June, 2011
Medical Consultant, PricewaterhouseCoopers

Provided medical consultation for payer operations on selected large payer clients including:
ICD-10-CM and ICD-10-PCS coding transition;
Medical management, including government, legislation, and accreditation processes, disease management, and utilization management;
Medical policy development, coding, implementation, and editing;
Claims submission/payment quality assurance, data analysis, audit, compliance, and research billing.

From December, 2009 – May, 2011 Medical Director, Program Integrity

Medicare RAC Validation Contractor
Provider Resources, Inc.
Duties and Responsibilities:
Served as Contractor Medical Director (CMD) for the Recovery Audit Contractor Validation Contractor overseeing the approval process for RAC Medical Review issues including automated and manual reviews, background federal regulations, CMS and MAC contractor policy for Medicare Part A, B, & DME claims;
Directed the Medical Review validation process for automated and complex RAC recoveries, including audit of claims review, payment policy, and reimbursement accuracy for Medicare Part A, B, & DME claims.
Provided medical direction on other government contracts including Veterans Administration, OIG, and Workman’s Compensation.

From February, 2009 – November 30, 2009
Lead Medical Director
National Government Services, Inc.
Duties and Responsibilities:
Served as Lead Medical Director for all National Government Services Medical Policy and Medical Review. Directs, manages, and leads physician efforts for National Government Services medical policy development and coverage for Medicare Part A, B, & DME;
Supervised medical necessity decision making for Medical Review, Claims, Data Analysis, Provider Outreach and Education, and Appeals departments;
Led the multi-departmental team that develop claims processing system edits as a result of the local coverage determinations (LCDs) and CMS national policy;
Provided oversight for Medical Review and Appeals guidelines and clinical review activities;
Developed clinical guidelines for claims adjudication;
Led Contractor Medical Directors’ (CMDs) relationships with physicians and other health care practitioners, and the Contractor Advisory Committees, related to LCDs and CMS Medicare coverage policies;
Led CMD activities with provider groups and institutional organizations for education concerning LCDs, National Government Services operations, and CMS Medicare coverage policies;
Led the data analysis enterprise for Medical Review and Medical Policy;
Medical lead for National Government Services ICD-10 coding project.

From August, 1998 – February, 2009
Medical Director, Medicare Part A
National Government Services
Duties and Responsibilities:
Served as Medical Director for Medicare Part A for Illinois, Indiana, Kentucky, and Ohio;
Identified the need for, and the development of, local medical guidelines and policies for Medicare Part A, including assessment of information on new procedures and technologies;
Rendered medical coverage and coding decisions in support of pre-payment and post-payment medical review, fair hearings requests, and fraud and abuse investigations;
Served as an internal and external medical information resource, particularly in the interpretation and application of coverage and coding;
Supervised medical review personnel on the use of internal medical review guidelines;
Represented the fiscal intermediary at national, regional, and local meetings of Medicare Medical Directors, including participation on national workgroups;
Spoke on behalf of the intermediary to professional medical organizations, locally, regionally, and nationally, on timely Medicare issues and contractor activities;
Undertook special projects in medical aspects of Medicare claims processing operations;
Coordinated the regionalization of Part A and B LCDs within National Government Services and with other local Medicare contractors;
Created and led the Data Analysis Team (DAT). The DAT coordinated all data analysis for pre- and post pay medical review and medical policy for all National Government Services contracts.

From November 5, 2001- February 15, 2002
Interim Medical Director, Medicare Part B
Indiana and Kentucky
AdminaStar Federal

From November 1, 1997 – August 28, 1998
Medical Director, Medicare Part A, RHHI
Health Care Service Corporation

In addition to serving as the contractor Medical Director for Medicare Part A, performed these functions for Medicare coverage of home health and hospice;
Wrote nationally implemented medical policies on hospice care for non-cancer diagnoses.

From April 20, 1994 – October 31, 1997
Associate Medical Director, Medicare Part B,
Illinois – RHHI, Illinois, Indiana, Ohio
Health Care Service Corporation

From October 14, 1991 – To July 26, 1994
Vice Chairman, Department of Psychiatry
Illinois Masonic Hospital Medical Center
Chicago, IL 60657
Duties and Responsibilities:
Chaired the quality assurance and utilization review committees for the department of psychiatry;
Attended departmental and executive committee meetings and acted in the Chairman’s place when absent;
Coordinated the Continuing Medical Education program for the department.

From July 1, 1991- To November 1, 1992
Associate Director, Katherine Wright Center
Duties and Responsibilities:
Assigned and supervise patients for 46 multispecialty mental health providers, including psychiatrists, clinical psychologists, licensed clinical social workers, clinical nurse specialists, and students from these disciplines;
Developed policies and procedures regarding standards for evaluation and treatment;
Developed policies and procedures for the administrative flow of work within the Center;
Designed curriculum for the learning of psychotherapy.

From February 1, 1990 – To July 1, 1991
Director, Integrated Therapies Unit
Illinois Masonic Hospital Medical Center Duties and Responsibilities:
Developed, instituted, and supervised an inpatient psychiatric treatment program for a ten-bed unit emphasizing an integrated biopsychosocial approach;
Developed an inservice education program for training in psychoanalytically informed approaches to the treatment of major mental illness;
Approved all patient admissions and monitored quality and appropriateness of care.

From July 1, 1982 – December 22, 1995
Private practice in psychiatry, psychoanalysis and addiction medicine

PROFESSIONAL ACTIVITIES

Professional Associations and Committees:

American Psychiatric Association, 1979 – Present
Fellow, 1991, Distinguished Fellow, 2003, Distinguished Life Fellow, 2014

Illinois Psychiatric Society, 1979 – Present
President, 1992-1993
President – Elect, 1991-1992
Councilor, 1985-1987
Editor, IPS Report (Society newsletter), 1984-1994
Committee memberships:
Chair, Ethics Committee, 1993-1995
Member, Ethics Committee, 1987-1995
Member, Managed Care Committee, 1991-1993
Member, Budget and Finance Committee, 1991-1993
Chair, Committee on Public Relations, 1984 -1988, 1993-1994
Co-chair, Residents Committee, 1980-1982

American Psychoanalytic Association, 1983 – 1999
Committee on Confidentiality, 1986 – 1988

Chicago Psychoanalytic Society, 1983 – 1999
Committee on Legislative Affairs, 1993 – 1997

American Medical Association, 1990 – Present

Illinois State Medical Society, 1990 – 2010
Chair, Council on Mental Health and Addiction, 1993-1994
Member, Council on Mental Health and Addiction, 1992-1995

Medicare Carrier Advisory Committee, 1992-1994

AWARDS/SPECIAL RECOGNITION

American Psychiatric Association, Newsletter Editor of the Year, 1991

BOARD CERTIFICATIONS

National Board of Medical Examiners, 1978

American Board of Psychiatry and Neurology, Psychiatry
Part I, May, 1984
Part II, June, 1985

OTHER CERTIFICATIONS

American Society of Addiction Medicine, 1989
AHIMA ICD-10 Train the Trainer Academy, July, 2010

EDUCATION

University of Illinois, Champaign-Urbana, Illinois, 1970-1974
B.A. in English Literature, May, 1974, Minors in Rhetoric and Chemistry
Academic Honors: Deans List 1970-1974
Alpha Epsilon Delta Honorary Premedical Society
Illinois State Scholarship Award

University of Illinois, Abraham Lincoln School of Medicine, Chicago, Illinois 1974-1978
M.D. degree, June, 1978
Academic Honors: James Scholar in Independent Study
Dr. Bertrand A Richardson Scholarship
Summer Research Fellowship, Department of Anatomy, 1975

University of Illinois, Abraham Lincoln School of Medicine, Department of Psychiatry
Residency Training Program, Chicago, Illinois, 1978-1982
Certificate of Completion of Residency, June 30, 1982
Academic Honors: American Psychiatric Association Falk Fellowship,
1980-1982

Institute for Psychoanalysis, Chicago, Illinois, 1983-1998

Northwestern University, 2003-2006, Masters Degree (MA) in Creative Writing

Indiana University Kelly School of Business, 2007-2008, Federal Government Solutions Strategic Leadership Program

Groups