HMO Expert Witnesses

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,...

Miami, Florida

Legal, HMO - Health Insurance, Health Maintenance Organization, Affordable Care Act, Preferred Provider Network, Medical Insurance, ERISA

Maria T. Santi, Esq, is a Legal advocate for Patients and Physician Directed Healthcare in Florida. She is a native Miamian and the founder of the Health and Medicine Law Firm. She obtained her JD with a certification in Health Law from Nova Southeastern University—Shepard Broad College of Law. Maria is actively involved with the Florida Bar serving on the Government Advocacy Committee, and as a member of the Health Law section. She is admitted to practice in Florida, Washington DC and the US Supreme Court. Her legal practice is focused on healthcare law, including legal disputes against Health Insurance Companies, Health Insurance Litigation for denied treatment and prescriptions, Medicaid and Medicare representation for appeals and administrative hearings for medical treatment denials, medical bill disputes and negotiations, and health insurance appeals. She also handles legal action under the Employment Retirement and Security Act ("ERISA"). She is also a Certified Human Rights C...

Yanceyville, North Carolina

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...

Bluffton, South Carolina

Hospital Administration, HMO - Managed Care & HMO, Negligent Physician Credentialing & PEER Review, Hospital Administration, Governance, Negligent Utilization Review, Healthcare Fraud & Abuse, Value Based Care (ACO), Defamation, Negligent Prior Authorization, Organizational Performance Evaluation, Quality Oversight, Medication Errors, HIPPA

Frank L Brown, Jr, MD, MBA, FCP, FACP is an administrative consulting and testifying expert witness who provides services involving healthcare systems. His background includes multidisciplinary training in pharmacy, medicine, and business from Howard University, Yale University, and Virginia Commonwealth University. Dr. Brown is retained by attorneys for his clear, objective, well-supported opinions; strong analytical skills; and the ability to communicate complex healthcare and administrative issues in a manner that is understandable, credible, and persuasive to judges, juries, arbitration panels, and administrative bodies. His work combines practical medical expertise with deep experience in healthcare quality, patient safety, accreditation, utilization management, pre-authorization, medical necessity, and organizational performance evaluation. He has served as an Examiner for both the Malcolm Baldrige National Quality Award and the National Committee for Quality Assurance, ev...

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...