Health Insurance Billing Fraud Expert

Case Description:

A health insurance billing fraud expert was needed for a regulatory dispute involving claims of fraudulent medical billing practices, improper chart coding, and allegations that standards of care regarding quality assurance (QA) were breached which compromised patient care. At issue was whether various health insurance plans were engaging in fraudulent practices equating criminal billing fraud and white collar crime.

IMS ExpertServices was asked to locate a health insurance billing fraud regulatory expert with particular experience in identifying patterns of fraudulent medical billing and improper chart coding which resulted in risky patient care and breach of quality assurance (QA) standards. This expert was needed to have relevant practical experience in health insurance billing administration, including billing quality assurance (QA) issues, audits, coding, and industry standards and practices for addressing billing anomalies.

Experts Presented:

  • AMA Standards Expert

    This expert has over thirty years of healthcare regulation and finance experience, including extensive knowledge of regulations involving third party payer requirements, particularly with respect to billing and coding. He is currently president of a private consulting group which specializes in regulatory compliance programs, fraud audits, risk assessment, and healthcare billing, compliance reviews, coding, and audits. His previous industry positions have included serving as director of patient financial services, director of business services, and medical auditor at a variety of hospitals. He is a certified Fraud Examiner, Assoc. of Certified Fraud Examiners (CFE), Certified Medical Investigator – Level II, American College of Forensic Examiners International (CMI-II), Diplomate of the American Board of Forensic Examiners (DABFE), Fellow of the Healthcare Financial Management Association (FHFMA), and Fellow of the American College of Forensic Examiners International (FACFEI). IMS Reference #5006337.

  • Healthcare Insurance Fraud Expert

    With over two decades of experience in health care regulation and healthcare fraud investigation, utilization, and quality assurance issues, this physician expert has served as a healthcare fraud consultant for a major hospital and a state’s attorney general on fraud and utilization issues. He is currently a consultant for a private physician review organization where he conducts utilization management, diagnosis-related group (DRS), appeal resolution, and quality assurance for clients. Formerly, he served as medical director of a major HMO and is a member of the American College of Utilization Review Physicians (ACURP). This expert holds board certification with the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP). IMS Reference #5077866.

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