Medical Billing Expert Witness California

Medical Billing Expert Witness California

Medical billing expert witness California work requires rendering opinions on the Usual Customary and Reasonable cost of care.   I receive questions on the difference between different types of care, codes and billing and the role of various entities in health care revenue cycle management and claims management. It is important to take into account inpatient and outpatient payment rules, federal and state statutes and industry best practices and guidelines.  The privacy and security of patient records being evaluated as prescribed under the HITECH Act or HIPAA must be considered including safeguards, policies and procedures to ensure the privacy and security of protected health information (PHI).  Medical billing expert witness work also requires a data driven approach.

Importantly, in personal injury cases where damages are being litigated and those damages include medical bills, many states have a “Collateral Source Rule” According to a recent Mondaq newsletter, California has no cap on either punitive or compensatory damages, and the collateral source rule applies. Medical billing expert witness California may need to work with counsel and understand various case law based on the facts in the case.  See Howell v. Hamilton Meats & Provisions, Inc., 257 P.3d 1130 (Cal. 2011).   Click here for a more detailed discussion of Howell v. Hamilton Meats and California rulings.

Also, the timing of expenditures in relation to inpatient care may be important.  Diagnosis codes including ICD-9 and ICD-10 CM as well as procedure codes, ICD-9 and ICD-10 PCS as well as outpatient procedures using the AMA standard Current Procedural Terminology (CPT®) HCPcS codes may be factors.  Inpatient stays may require review of Diagnosis Related Groupings (DRGs) using the IPPS system (inpatient prospective payment system).  Outpatient Prospective Payment System (OPPS) or Ambulatory Procedure Codes (APCs) may apply in an Ambulatory Surgery Center (ASC). Additionally, payments via various payors whether private insurance, Medicare and Medicaid via the Centers for Medicare and Medicaid may be factors.  Medical codes are determined by coders who rely on physician or physician assistant diagnosis and prescribed procedures.  Additionally, diagnostic imaging, pharmaceuticals and durable medical equipment costs (DME) may be factors.

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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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