Utilization Management Expert Witnesses

Roseville, California

Addiction Medicine, Family Medicine - Opioids, opiate, methamphetamine, overdose, alcohol, hallucinogens, cocaine, toxicology, sober living, drugs, illicit, drug rehabilitation, utilization management, drug policy, alcohol and drug treatment, drug intoxication, withdrawal, detoxification, drug testing appropriateness, pain

Dr. Mario San Bartolome is board-certified in Addiction Medicine and Family Medicine and has extensive clinical, administrative, regulatory, and forensic experience in the evaluation and treatment of substance use disorders, co-occurring psychiatric conditions, controlled-substance prescribing, detoxification, withdrawal management, toxicology, and addiction-related standards of care. Dr. San Bartolome has served as a medical director across multiple levels of addiction treatment, including withdrawal management/detoxification, residential treatment, intensive outpatient care, outpatient addiction medicine, and managed care. His experience includes policy development, clinical protocol design, utilization management, peer review, quality oversight, direct patient care, and maintaining patient safety in drug and alcohol treatment programs. He has practiced and consulted in settings that include hospitals, psychiatric units, emergency departments, correctional environments, outpatien...

Santa Monica, California

Family Medicine, Geriatrics - family medicine, primary care, general medicine, urgent care, managed care, utilization management

I have vast experience providing medical legal expertise for both medical defense as well as plaintiff counsels. I also serve as an expert for the medical board of California. I have been in clinical practice for 34 years in the Los Angeles area, 21 years in private/group practice and 13 years in outpatient family medicine in a community practice affiliated with UCLA. I also serve as medical director for the UCLA primary care network, and am involved in clinical operations as well as quality improvement activities for the primary care physicians. The network includes primary care offices as well as urgent care locations and also incorporates telehealth services. While I no longer provide inpatient care, I do maintain hospital privileges at 2 community hospitals and follow my patients closely upon hospital discharge. I have vast experience in managed care, providing utilization review for health plan beneficiaries under HMO insurance. My clinical practice includes pediatrics, ad...

Chicago, Illinois

Public Health, Hospital Administration - medical necessity, utilization management, Insurance clinical policy reviews, managed care, obstetrics, gynecology

Board Certified Obstetrician and Gynecologist with more than 3 decades of experience in healthcare. Experience with peer review including 10 years on State Medical Disciplinary Board. More than a decade of experience as Medical Director on provider and payor side, authoring policies and procedures, performing medical necessity review with specialization in prior authorization.

Roseville, Minnesota

Hospitalist, Medical Coding - clinical validation, DRG validation, inpatient versus observation, hospital reimbursement, physician advisor, CDI, diagnosis denial, documentation adequacy, utilization management, auditor denials, AKI, malnutrition, acute respiratory failure, encephalopathy, sepsis, CDI query compliance, level of care, DRG reassignment

Matthew K. Turner, MD, CCDS is a board-certified internal medicine physician, actively practicing hospitalist, and physician advisor who serves as system medical director for clinical documentation integrity (CDI) in a large integrated health system. His work centers on clinical validation, DRG validation, documentation adequacy, level-of-care determinations, and payer or auditor disputes involving hospital reimbursement. Since 2020, Dr. Turner’s work has included both CDI and utilization management physician-level review. In his CDI leadership roles, he has performed more than 500 physician-level clinical validation reviews involving provider-disputed queries, escalations, and prospective query appropriateness consultations; reviewed more than 100 auditor-initiated diagnosis denials since 2022 in which denial of a specific diagnosis typically resulted in DRG reassignment and reduced reimbursement; and prepared written clinical justifications and participated in peer-to-peer discus...

Saint Louis, Missouri

Insurance, Medical Management - Medicaid, Managed Care, Medicare, Dual Eligible, Marketplace, Medical Policy, Utilization Management, Risk Management, Payer Operations, Quality Improvement, Regulatory Compliance, Expert Witness, Internal Medicine, Corporate Compliance, Medicare Advantage, Utilization Review, Access to Care, Population Health, Insurance

Physician executive, internist, MBA, and thought leader in managed care with 27 years of leadership experience across Medicaid, Medicare, Dual Eligible/D-SNP, Marketplace, utilization management, medical policy, quality performance, population health, and payer operations. Former Senior Vice President and Corporate Chief Medical Officer for Centene, a Fortune 25 healthcare enterprise, and Washington University faculty member with extensive experience in enterprise clinical strategy, risk management, and work with corporate lawyers, corporate compliance, and senior leadership on litigation-related matters, depositions, fair hearings, regulatory issues, medical affairs, and complex managed care operations Washington University faculty member, with appointments in the School of Medicine, School of Law, Olin Business School, and Brown School of Social Work. Board-certified internist, Fellow of the American College of Physicians, and Missouri-licensed physician. Earned an MD from Washin...

Pittsburgh, Pennsylvania

Emergency Medicine, Legal - Medicare Billing, Utilization Management, Medicaid Billing, Health Insurance Fraud

San Antonio, Texas

Preventive Medicine, Family Medicine - Health Insurance, Utilization Management, Government Contracts, Quality, Outbreak, Communicable Diseases, TRICARE, Medicare, Medicaid, HIV, LGBT care, Migrant Care, Non-profit or indigent care, Correctional facility care, Denial/Appeals, Academic health, Population health, Tuberculosis, Non-Profit

Executive Physician and former Chief Medical Officer with extensive leadership experience across public health, health insurance, complex health systems, government agencies, and nonprofit organizations. Brings deep clinical, administrative, and policy expertise to cases involving population health, disease prevention, standards of care, health plan operations, and organizational oversight. Areas of Expertise Public Health • Preventive Medicine • Family Medicine • Population Health • Health Insurance and Health Plan Operations • Clinical Oversight and Standards of Care • Utilization Management, Denials, Case and Disease Management • Outbreak and Contamination Response • Disaster Health • Clinical Quality Improvement and HEDIS Attainment • Accreditation and Certification • Clinical Safety • Provider Network Credentialing • Social Determinants of Health • Health Equity • Government Health Programs (Federal, State, Local) • Clinical Analytics, Metrics, AI and Predictive Analytics • Pub...

Spokane, Washington

Chiropractic, Physical Medicine & Rehab - Independent Medical Examinations IME, File Review, Utilization management, Quality Assurance, Medical Record Review, Motor Vehicle Accident Injury, Disability Rating, Failure to Diagnose, Chiropractic Peer Review, Malpractice, Causation, Medical Necessity, Billing Reviews, Standard of Care, Apportionment, Negligence

I have over 25 years of extensive clinical experience. Along with regular patient care as a Chiropractor who practices in a large Medical Group, I specialize in evaluating patients for Independent chiropractic examinations (IME’s) and thorough medical file reviews for disability ratings, fraudulent practice and billing cases, documentation and case reviews for insurance companies and third-party payers. I have provided depositions and have testified as an expert witness for spinal injuries involving work accidents and motor vehicle collisions By conducting comprehensive reviews and making evidence-based decisions, I effectively recommend appropriate levels of care while maximizing resources and minimizing unnecessary expenses. I am also a Certified Chiropractic Insurance Consultant, having completed the 100 hour advanced training course accredited through the C.C.E. I pride myself on prompt turnaround for completion of cases. I am on the Physician Advisory Board of the Center fo...