This case involves an alleged breach of contract between a rehabilitation services system and a health insurance company in Arizona. The plaintiff system alleged that the health insurance company underpaid for inpatient rehabilitation services. It was also alleged that the health insurance company paid for the inpatient rehabilitation services as if they were another category of services, the latter of which is paid at a much lower rate. An expert was requested to examine the various claims forms that were submitted and evaluate the contract in order to determine whether there has been underpayment by the health insurance company for the services provided by the rehabilitation system.
Question(s) For Expert Witness
- 1. How long have you been involved in the healthcare/health insurance industry, and in what capacity?
- 2. Do you have experience evaluating claims and contracts?
Expert Witness Response E-103196
I have been in healthcare administration for 20 years in various health systems, with responsibility for billing, insurance, network contract administration, collections, admissions, pre-admission testing, and other departments directly related to the revenue cycle of hospital. I have been the President of my health claims auditing company for 14+ years, where I direct and perform claims audits throughout the U.S. In every aspect of my career (hospital, auditing, and legal cases), I have had responsibility for evaluating claims and contracts. I am familiar with reimbursement variances in different levels of care based on negotiated contract terms. I have reviewed similar cases. One was for a federal case involving a major insurance claims administrator and a major self-insured employer. This case involved the analysis of many contracts and the claims administrator to administer the terms accurately creating millions of dollars in overpayments.
Expert Witness Response E-050744
I’ve been involved in the healthcare/insurance industry for 35 years as a physician, medicare medical director, and consultant. I have extensive experience evaluating claims, viatical settlements, claims data, and medical records for accuracy, compliance, and appropriate billing and reimbursement. I’m familiar with all aspects of the differences between inpatient rehab and acute inpatient services, including reimbursement, billing mechanisms, and clinical services. I’ve served as expert in two arbitration cases where the dispute was whether services should be reimbursed as acute inpatient versus residential. I served as a Medicare Medical Director for Medicare Part A, the part that processes claims and reviews services for both inpatient rehabilitation and acute inpatient services, so I am very familiar with both these levels of care.