Medical Billing & UCR Reimbursement Expert Witness

Specialties & Experience of this Expert Witness

Additional Information

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 includes: - Billing and coding accuracy (CPT, HCPCS, ICD) - Usual, customary, and reasonable (UCR) analysis - Out-of-network reimbursement disputes - ERISA and managed care payment methodologies - Claims denial patterns and audit findings - Medicare, Medicaid, and commercial payer compliance - Medical record and billing documentation review I have testified in depositions and trial proceedings and have been retained in matters involving hospitals, physician groups, ambulatory surgery centers, and independent providers. I have been retained by both plaintiff and defense counsel in complex reimbursement and billing disputes, providing independent and objective analysis. In addition to litigation support, I have held executive leadership roles overseeing large-scale billing operations, including multi-state imaging centers and hospital-based systems. I have also developed internal audit programs, denial management strategies, and compliance protocols aligned with CMS and regulatory standards. I am a Certified Professional Coder (CPC) and Certified Medical Reimbursement Specialist (CMRS), and have served as an educator providing continuing education to healthcare professionals. My expert opinions are based on industry standards, regulatory guidance, and systematic analysis of billing records, payer policies, fee schedule benchmarks, and accepted reimbursement methodologies. I apply consistent, replicable frameworks to assess whether charges, payments, and denials align with accepted healthcare reimbursement practices. I am available for case review, rebuttal analysis, and expert testimony.