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 is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See and for more about the company.

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