Hmo Expert Witnesses

HMO, Insurance - prior authorization, PA, Medicare Advantage, MA, Outpatient authorization, Inpatient authorization, Post Acute authorization, Appeals, documentation standards, managed care, helicopter transportation

As a physician leader, I have designed and implemented systems to ensure medical recordkeeping meet legal, reimbursement, and quality benchmarks. I spearheaded the development of a multi-state governance framework for both primary and specialty care groups, ensuring peer review, credentialing, quality assurance, and utilization management processes are rigorously structured and defensible. I also led the creation of an enterprise-wide Utilization Management Committee to meet CMS mandates. The committee is empowered to critically evaluate national clinical policies before adoption—aligning frontline utilization decisions with evidence-based standards. With decades of expanding leadership across diverse healthcare sectors, I bring a fair, balanced, and meticulously documented expert perspective to every case I consider. Tradewinds Healthcare Consulting, LLC 04/2025 - Present - Consulting Expert - Testifying Expert - Clinical case review Humana, Inc. 08/2023 - 04/2024...

California

Medical Billing, Insurance - Managed Care, HMO, PPO, Medicare, Medicaid, Reasonable Value, Audit, Hospital, ERISA, Usual and Customary, Reimbursement Disputes, Claims Denials, Athena Billing, Out-of-Network, Balance Billing, Fee Schedule Analysis, Expert Testimony, Medical Necessity, Multi-State, Healthcare Reimbursement

I have over 35 years of experience in medical billing, reimbursement, and managed care systems, with expertise spanning provider operations, payer methodologies, and claims adjudication practices. My work focuses on evaluating medical billing accuracy, reimbursement methodologies, usual and customary charges, and payer denial practices. Practice includes multi-state reimbursement analysis, with extensive experience in California managed care systems, including HMO, IPA, and risk-based reimbursement structures, as well as Medicare Advantage and national payer methodologies. I have served in multiple roles, including claims examiner, billing manager, revenue cycle executive, and founder of a national medical billing and audit firm. This multidisciplinary experience allows me to analyze disputes from both the provider and payer perspectives. Experience includes analyzing billing system workflows and claims processing issues across platforms such as Athenahealth. My expert work includ...

Oceanside, California

Geriatrics, Nursing Homes - Nursing Home - Skilled Nursing Facility, Hospice - End-of-Life Care, Palliative Care, Home Health, Assisted Living, Regulatory, Decubitus, Pressure Ulcers, Falls, Dementia - Alzheimer's, Medicare, Medicaid, Managed Care - HMO, Life Care Planning, Personal Injury, Family Medicine, Addiction Medicine, Bioethics

Experienced Expert, 250+ depositions, 25+ trials. Speedy and Objective Records Reviews (plaintiff/defense); Standard of Care, Causation and Damages Opinions, including Life Expectancy and Future Care Costs, Regulatory Actions; Comprehensive Report Writing. References Available on Request. In clinical practice of post-acute and long-term care medicine, Geriatrics & Hospice in San Diego area since 1992; Chief Medical Officer, Bio-Pacific Admin Services (nursing facility management company); Chief Medical Officer, Beecan Health; Delegate, AMA and California Medical Association House of Delegates; Chair, CMA Council on Ethical, Legal & Judicial Affairs; Chair, CMA Administrative Medicine Forum; Clinical Faculty UCSD School of Medicine and Family Medicine Dept., Affiliate Faculty, California State University's Shiley Haynes Institute for Palliative Care (San Marcos), Past President of CALTCM, Past President of PALTmed (Post-Acute & Long-Term Care Medical Association, previously AMDA,...

Bluffton, South Carolina

Hospital Administration, HMO - Managed Care, Physician Credentialing, Medical Expert, Drugs, Corporate Practice of Medicine, Healthcare Fraud, Value Based Care, Defamation, Physician Sanctions, Medical Records Review, Medical Management, Pharmacology, Health Literacy, Medical Administration, HIPPA, Patient Safety & Quality, Health Equity, Accountable Care Orgs, HMO

FRANK L BROWN, JR, MD, MBA, FCP, FACP My education has been in pharmacy, medicine, and business at Howard University, Yale University, and Virginia Commonwealth University, respectively. I have served as an Examiner for the Malcolm Baldrige National Quality Award, as well as the National Committee for Quality Assurance. Areas of expertise developed by me include: • Credentialing • Defamation • Health Disparity • Health Equity • Health Literacy • Healthcare Fraud/Qui Tam • HMO & Managed Care • Pharmacology • Pre-authorization • Value-Based Care/ACO Key metrics managed during my career include the conduct of over 5,000 physician credentialing reviews; over 5,000 medical necessity/utilization management reviews; and over 2,000 patient/physician committee and in-person grievance & appeal reviews; and the planning, organizing, development, staffing and monitoring of programs for patient quality of care, and safety. I hold patents for improved emergency patient flow system design a...

McKinney, Texas

Medical Billing, Insurance - Managed Care, HMO, PPO, Medicare, Medicaid, Reasonable Value, Audit, Hospital, ERISA, Usual and Customary, Reimbursement Disputes, Claims Denials, Athena Billing, Out-of-Network, Balance Billing, Fee Schedule Analysis, Expert Testimony, Medical Necessity, Multi-State, Healthcare Reimbursement

I have over 35 years of experience in medical billing, reimbursement, and managed care systems, with expertise spanning provider operations, payer methodologies, and claims adjudication practices. My work focuses on evaluating medical billing accuracy, reimbursement methodologies, usual and customary charges, and payer denial practices. Practice includes multi-state reimbursement analysis, with extensive experience in California managed care systems, including HMO, IPA, and risk-based reimbursement structures, as well as Medicare Advantage and national payer methodologies. I have served in multiple roles, including claims examiner, billing manager, revenue cycle executive, and founder of a national medical billing and audit firm. This multidisciplinary experience allows me to analyze disputes from both the provider and payer perspectives. Experience includes analyzing billing system workflows and claims processing issues across platforms such as Athenahealth. My expert work includ...