Healthcare Expert witness, HIPAA, HITECH Act, Medical Coding and Affordable Care Act Considerations

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Michael Arrigo affordable care act, medical coding and billing expert witness, Usual Customary and Reasonable cost of care. Published author and speaker. Contact here.
Michael Arrigo affordable care act, medical coding and billing expert witness, Usual Customary and Reasonable cost of care. Published author and speaker. Contact here.

In health care expert witness work regarding the usual customary and reasonable cost of care, medical coding and billing, HIPAA Privacy, HITECH Act, and cost of future care I receive questions regarding how to determine the value of not only historical care but future care.

No where else is this more true than when considering the Affordable Care Act.  In personal injury and medical malpractices cases, sometimes there is a question as to the value of future care for patients (also known as ‘life care plans’).  The Patient Protection and Affordable Care Act (“PPACA,” or Affordable Care Act, or “Obama Care”) as it is sometimes known has several provisions regarding care coverage and eligibility determinations.    Additionally, it may be prudent to consider the cost of care with respect to Medicaid expansion and also certain provisions for individuals with specific medical diagnosis or financial conditions.

  1. Medical records, medical diagnosis codes and medical procedure codes for billing: Expert witnesses may need to consider medical records and patient coding as only part of the elements that should be considered.
  2. Payors and insurance  policies: Many times for an expert witness, these factors must be considered when determining the best strategy for working with plaintiff’s or defense counsel.    Additionally, risk adjusted (sometimes called value based care) under Medicare Part C and Accountable Care Organizations may also be a factor.
  3. Medical specialties, and the payor policies for reimbursement within those specialties, whether orthopedics, cardiology, dental pain management, other surgical procedures, as well as long term care may be considerations.  These various procedures may be expressed as CPT codes, CDT (“D” codes), ICD-9, ICD-10, or Diagnosis Related Grouping (DRGs).
  4. Diagnostic imaging: Various modalities of diagnostic imaging as well as the setting where these diagnostic imaging services were performed may also be factors (MRI, X-Ray, PET / CT Scan, etc.).  The charge components of diagnostic images are also factors.
  5. Lab reports / pathology coding and the value of billed services
  6. Geography and wage indices put forth by the office of management and budget and instantiated in CMS / Medicare rates may be factors.
  7. Affordable Care Act repealed or not repealed: Even if parts of the Affordable Care Act were to be repealed, the industry best practices that have been instantiated by recent regulations may also be an important consideration.
  8. Medical necessity, utilization management and other coverage determination factors put forth by medical opinions and medical policy of payors may be factors.
  9. HIPAA, HITECH Act, in UCR determinations and discovery strategies.  There are unintended consequences of provisions of the statutes with regard to meaningful use of electronic health records and discovery, what disclosures are permissible under HIPAA, and the methods to calculate UCR when a patient has inpatient, outpatient including emergency room (level 1, level 2 etc.), recovery room costs, or specialized behavioral health or long-term care needs.

In conclusion, a skilled expert witness or expert consultant works in partnership with the litigation team to assist in various aspects of discovery and testimony whether in expert reports, depositions or in trial appearances.[/fusion_builder_column][/fusion_builder_row][/fusion_builder_container]

Michael F. Arrigo

Michael Arrigo, an expert witness, and healthcare executive, brings four decades of experience in the software, financial services, and healthcare industries. In 2000, Mr. Arrigo founded No World Borders, a healthcare data, regulations, and economics firm with clients in the pharmaceutical, medical device, hospital, surgical center, physician group, diagnostic imaging, genetic testing, health I.T., and health insurance markets. His expertise spans the federal health programs Medicare and Medicaid and private insurance. He advises Medicare Advantage Organizations that provide health insurance under Part C of the Medicare Act. Mr. Arrigo serves as an expert witness regarding medical coding and billing, fraud damages, and electronic health record software for the U.S. Department of Justice. He has valued well over $1 billion in medical billings in personal injury liens, malpractice, and insurance fraud cases. The U.S. Court of Appeals considered Mr. Arrigo's opinion regarding loss amounts, vacating, and remanding sentencing in a fraud case. Mr. Arrigo provides expertise in the Medicare Secondary Payer Act, Medicare LCDs, anti-trust litigation, medical intellectual property and trade secrets, HIPAA privacy, health care electronic claim data Standards, physician compensation, Anti-Kickback Statute, Stark law, the Affordable Care Act, False Claims Act, and the ARRA HITECH Act. Arrigo advises investors on merger and acquisition (M&A) diligence in the healthcare industry on transactions cumulatively valued at over $1 billion. Mr. Arrigo spent over ten years in Silicon Valley software firms in roles from Product Manager to CEO. He was product manager for a leading-edge database technology joint venture that became commercialized as Microsoft SQL Server, Vice President of Marketing for a software company when it grew from under $2 million in revenue to a $50 million acquisition by a company now merged into Cincom Systems, hired by private equity investors to serve as Vice President of Marketing for a secure email software company until its acquisition and multi $million investor exit by a company now merged into Axway Software S.A. (Euronext: AXW.PA), and CEO of one of the first cloud-based billing software companies, licensing its technology to Citrix Systems (NASDAQ: CTXS). Later, before entering the healthcare industry, he joined Fortune 500 company Fidelity National Financial (NYSE: FNF) as a Vice President, overseeing eCommerce solutions for the mortgage banking industry. While serving as a Vice President at Fortune 500 company First American Financial (NYSE: FAF), he oversaw eCommerce and regulatory compliance technology initiatives for the top ten mortgage banks and led the Sarbanes Oxley Act Section 302 internal controls I.T. audit for the company, supporting Section 404 of the Sarbanes Oxley Act. Mr. Arrigo earned his Bachelor of Science in Business Administration from the University of Southern California. Before that, he studied computer science, statistics, and economics at the University of California, Irvine. His post-graduate studies include biomedical ethics at Harvard Medical School, biomedical informatics at Stanford Medical School, blockchain and crypto-economics at the Massachusetts Institute of Technology, and training as a Certified Professional Medical Auditor (CPMA). Mr. Arrigo is qualified to serve as a director due to his experience in healthcare data, regulations, and economics, his leadership roles in software and financial services public companies, and his healthcare M&A diligence and public company regulatory experience. Mr. Arrigo is quoted in The Wall Street Journal, Fortune Magazine, Kaiser Health News, Consumer Affairs, National Public Radio (NPR), NBC News Houston, USA Today / Milwaukee Journal Sentinel, Medical Economics, Capitol ForumThe Daily Beast, the Lund Report, Inside Higher Ed, New England Psychologist, and other press and media outlets. He authored a peer-reviewed article regarding clinical documentation quality to support accurate medical coding, billing, and good patient care, published by Healthcare Financial Management Association (HFMA) and published in Healthcare I.T. News. Mr. Arrigo serves as a member of the board of directors of a publicly traded company in the healthcare and data analytics industry, where his duties include: member, audit committee; chair, compensation committee; member, special committee.

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