HMO Expert Witnesses

San Marino, California

Internal Medicine, Hospitalist - Medical Director, HMO, Medicare Advantage, Insurance, HCC, RAF, Coding, Billing, Contracts

Dr. Ji is a Los Angeles based board certified internal medicine physician with experience as a medical director and practicing hospitalist physician since graduating residency in New York in 2013 (Columbia University/New York Presbyterian Hospital). Since then he has had: 10+ years of experience as a hybrid hospitalist and office based internal medicine physician in active practice 7+ years of medical director experience for two large medical groups (Regal Medical Group and Caremore) Additional experience and expertise include clinical and management expertise in: -value based care and risk bearing models of care -PCP/specialist and hospital contracting -HCC/RAF coding -STARS/HEDIS -High risk population management (inpatient and outpatient) -Insurance based bed day management (inpatient/observation determination, and out-of-network and patient transfer management) -Extensive case review experience with physician quality/standards, hospital coding, appeals determination including...

California

Medical Billing, HMO - Managed Care, HMO, PPO, HIPAA, Medical Billing, Capitation, IPA, Medical Group, Medicare, Medi-Cal, Medicaid, POS, Athena, Nationwide, California, Texas, Florida, Arizona, Colorado, Washington

Do you need someone who knows and understands medical billing? I have been in the industry since 1988. I know the games and tricks payers use to deny claims. I have been a claims examiner, biller, claims manager, medical billing company owner, and a highly sought-after lecturer. I am not some Johnny-come-lately. I have the tools that you need to succeed. • EXPERIENCE ACCURATE MEDICAL BILLING & AUDIT, Rancho Cucamonga, CA/McKinney, TX OWNER, CEO, AND FOUNDER Only Billing Service to earn Preferred partner status with San Bernardino County Medical Society. Only billing services are authorized in California to perform CEUs for doctors. Comprehensive knowledge and experience in insurance billing, claims, and collections. Recommended billing service by and to CCA members Recommended and endorsed by ICAC Co-Chair insurance and Managed Care Committee-California Chiropractic Association CONSOLIDATED HEALTHCARE SERVICES/A1 IMAGING/HALLMARK SURGERY CENTER NATIONAL DIRECTOR BILLING/COL...

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 - MA, Medicare Advantage, Medicare Operations, Prior Authorization, PA, Appeals, Managed Care, Prior Authorization, Utilization Review, Utilization Management, Senior Care

Edited for Relevant Experiences National Utilization Committee August 2023 - April 2024 - led the effort to create governance, workflow and procedural requirements to meet CMSS rules changes effective 1/1/2024 - Accountabilities described below and added above responsibility National Director Medicare Operations March 2022 - April 2024 - Grievances and Appeals - STARS Appeals performance - Outpatient Prior Authorization Operations - Collaborated on national work groups/task forces Regional VP Mid-Atlantic State March 2019 - March 2022 - Oversight of Prior Authorization and Concurrent Review Operations - Collaborate on Enterprise Clinical Delivery Models of Care National reviewing medical Director March 2018 - March 2019 - Reviews prior authorizations for medical necessity V.P. Integrated Care and Associate CMO Jan 2015 - March 2018 - Multi-state prim...

Bluffton, South Carolina

HMO, Medical Management - HMO & Managed Care, Appeals & Grievances, Hospital & Provider Creden, Privileging, Utilization/Medical Necessity, Healthcare Fraud/Abuse, Physician Contracting, Physician Defamation, Physician Sanctions, Physician Sanctions, Medical Management, Disease Management, Quality & Patient Safety, Qui Tam

AMERICLIN® MEDICAL EXPERTS (AME) is a physician-led collaborative of skilled consulting clinical expert witnesses. There are currently over 50 clinicians in the AF network who seek to provide case-winning strategies for lawyers nationwide. Upon contacting us, we provide a no-charge consultation to discuss the case. Our full suite of services includes: • Free initial phone consultations with expert clinicians • Flat fee initial case reviews • Dynamic clinical case theory analysis and development Phone: (843) 949-0927 Email: [email protected] AREAS OF EXPERTISE: Accountable Care Organizations Appeals & Grievances Case Management Correctional Healthcare Defamation Disease Management Disruptive Physicians Elder Abuse Emergency Medicine Geriatrics Healthcare Fraud/Abuse HMO & Managed Care Hospital & Provider Credentialing Internal Medicine Medical Insurance Medical Necessity Patient Grievances and Appeals Patient Safety Pharmacy Pharmacology Physician Burnout Physician Cred...

McKinney, Texas

Medical Billing, HMO - Managed Care, HMO, PPO, HIPAA, Medical Billing, Capitation, IPA, Medical Group, Medicare, Medi-Cal, Medicaid, POS, Athena, Nationwide, California, Texas, Florida, Arizona, Colorado, Washington

Do you need someone who knows and understands medical billing? I have been in the industry since 1988. I know the games and tricks payers use to deny claims. I have been a claims examiner, biller, claims manager, medical billing company owner, and a highly sought-after lecturer. I am not some Johnny-come-lately. I have the tools that you need to succeed. • EXPERIENCE ACCURATE MEDICAL BILLING & AUDIT, Rancho Cucamonga, CA/McKinney, TX OWNER, CEO, AND FOUNDER Only Billing Service to earn Preferred partner status with San Bernardino County Medical Society. Only billing services are authorized in California to perform CEUs for doctors. Comprehensive knowledge and experience in insurance billing, claims, and collections. Recommended billing service by and to CCA members Recommended and endorsed by ICAC Co-Chair insurance and Managed Care Committee-California Chiropractic Association CONSOLIDATED HEALTHCARE SERVICES/A1 IMAGING/HALLMARK SURGERY CENTER NATIONAL DIRECTOR BILLING/COL...