Expert Details
Healthcare, Medical Device, Diagnostics, Pharmaceuticals coding, reimbursement
ID: 725000
Arizona, USA
Executive clinician with over 30 years of experience providing strategic leadership and medical oversight to data-driven health organizations. Skilled in strategy, development and implementation of innovative health programs, products and payment systems, with extensive experience in clinical practice, research, coverage, reimbursement, quality improvement, bundled and episode payments, and value-based care.
He is Board Certified in Internal Medicine and Gastroenterology. He has run risk-bearing Independent Practice Associations and Physician-Hospital Organizations in California and Arizona. He is a consultant to Employer, Inc. and the Chief Medical Officer of Predictive Health, LLC. He has held management positions and currently serves on Scientific Advisory Boards / Committees for several managed care companies and a member of the Editorial Advisory Boards for several journals. He works extensively with the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) on coding, coverage and reimbursement issues, served as the Co-Chair of the Part D medication measures Technical Expert Panel for CMS, and works with specialty societies and other organizations on quality improvement, accountable care, bundled payment, and measure development projects.
He participates in the CPT Editorial Panel and the AMA RBRVS Update Committee (RUC). He is the author of several guidelines / quality measures in Gastroenterology and Preventive Services, and the lead physician for the American Gastroenterological Association (AGA) Bundled Payment Project, which has developed an episode methodology, claims payment, warranty and outcomes measures for outpatient procedures. He is the co-founder of the AGA Center for GI Innovation and Technology, which has developed observational comparative effectiveness registries.
Expert is an Assistant Clinical Professor of Medicine at the University of Arizona College of Medicine, and an Adjunct Assistant Professor of Medicine at Midwestern University.
He received his undergraduate A.B. Biology at the University of California, Los Angeles, and graduated from the Rosalind Franklin University of Medicine and Science - Chicago Medical School. He completed his Internship and Residency in Internal Medicine at the UCLA – San Fernando Valley Program, and a fellowship in Gastroenterology at Los Angeles County – USC Medical Center. He completed the Management Program for Health Care Organizations at the UCLA School of Public Health.
Assisted professional society with achieving CPT codes for their procedureAssisted in development of new CPT codes and reimbursement for infusion therapy
Education
| Year | Degree | Subject | Institution |
|---|---|---|---|
| Year: 1980 | Degree: MD | Subject: Medicine | Institution: Chicago Medical School |
| Year: 1976 | Degree: AB | Subject: Biology | Institution: UCLA |
| Year: 1983 | Degree: Internship and Residency | Subject: Internal Medicine | Institution: UCLA |
| Year: 1985 | Degree: Fellowship | Subject: Gastroenterology | Institution: University of Southern California |
| Year: 1994 | Degree: Certificate Program | Subject: Management of Health Care Organizations | Institution: University of California, Los Angeles School of Public Health |
Work History
| Years | Employer | Title | Department |
|---|---|---|---|
| Years: 2011 to Present | Employer: Undisclosed | Title: Medical Director | Department: |
Responsibilities:Executive clinician with 30 years of experience providing strategic leadership and medical oversight to large data-driven health organizations. Skilled in strategy, development and implementation of innovative health programs, products and payment systems, with extensive experience in clinical practice and research. Clinical subject matter expert in developing products including Workers’ Compensation; ambulatory surgery centers, medical/surgical professional services; injectable/infused pharmaceuticals; laboratory and molecular diagnostic services; durable medical equipment; Medicare GapFill; bundled/episode products for selected clinical procedures and conditions; and consumer-facing products. |
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| Years | Employer | Title | Department |
| Years: 2003 to Present | Employer: Undisclosed | Title: Chief Medical Officer | Department: |
Responsibilities:Chief Medical Officer which performs predictive modeling analysis of medical and pharmaceutical claims data and implements proactive patient care management solutions. His areas of focus include coding and reimbursement methodologies for emerging medical devices and pharmaceuticals, healthcare business strategy, quality improvement and medical management. |
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| Years | Employer | Title | Department |
| Years: 2001 to 2003 | Employer: CLS SERVICES | Title: Chief Medical Officer | Department: |
Responsibilities:Consulting group that assisted clients to establish comprehensive outpatient rehabilitation facilities and independent diagnostic testing facilities, providing services in rehabilitation medicine and diagnostic sleep testing. |
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| Years | Employer | Title | Department |
| Years: 1999 to 2001 | Employer: RxANALYST | Title: Chief Medical Officer | Department: |
Responsibilities:• Founded company and developed information management system allowing managed care organizations to integrate pharmacy, laboratory and medical data to implement disease management, quality improvement, and audit analysis programs |
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| Years | Employer | Title | Department |
| Years: 1997 to 1999 | Employer: GILA RIVER HEALTH CARE CORPORATION | Title: Chief Medical Officer | Department: |
Responsibilities:Working with the Rural Health Office at the University of Arizona, he assisted in the development of a model enabling American Indian tribes to privatize their health care system from the Indian Health Service. |
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| Years | Employer | Title | Department |
| Years: 1995 to 1997 | Employer: BLUE SHIELD OF CALIFORNIA | Title: Medical Director | Department: |
Responsibilities:Direct responsibility for utilization management and quality improvement for 1.2 million HMO and PPO members in California• Implemented multidisciplinary utilization management teams, coordinated specialty physician reviewers for geographically focused medical management teams, developed medical technology coverage guidelines, implemented disease management programs, created utilization guidelines for injectable pharmaceutical program, participated in plan underwriting decisions, implemented closed and tiered formulary programs to support medical management and wellness objectives |
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| Years | Employer | Title | Department |
| Years: 1985 to 1995 | Employer: COVINGTON, MENZ AND BRILL MD’s | Title: Gastroenterologist | Department: |
Responsibilities:• Implemented computer system for specialty group practice• Assessed outpatient endoscopy center joint ventures • Developed clinical guidelines for primary care evaluation of GI disorders • Coordinated community based follow-up for liver transplant patients |
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Career Accomplishments
| Associations / Societies |
|---|
| American Gastroenterological Association American Society for Gastrointestinal Endoscopy American College of Physicians American College of Gastroenterology American Medical Association PROFESSIONAL AFFILIATIONS: American College of Physicians American Gastroenterological Association American College of Gastroenterology American Society for Gastrointestinal Endoscopy American Society of Addiction Medicine American Medical Association Arizona Medical Association |
| Licenses / Certifications |
|---|
| MD LICENSURE: Arizona California Indiana |
| Professional Appointments |
|---|
| Assistant Clinical Professor of Medicine at the University of Arizona School of Medicine. Adjunct Assistant Professor of Medicine at Midwestern University University of Arizona, College of Medicine, Phoenix Clinical Assistant Professor of Medicine Midwestern University Adjunct Assistant Professor of Medicine WP Carey School of Business, Arizona State University Lecturer, School of Health Management & Policy MACRA Episode-Based Clinical Committee Gastrointestinal Disease Management Clinical Subcommittee Arizona Area Health Education Centers Commission Board of Regents Appointee American Gastroenterological Association Physician Lead, Gastroenterology Bundled Payment Initiatives Physician Advisor, Digestive Health Recognition Program Chair, Practice Management and Economics Committee Member, Practice Management and Economics Committee Member, Clinical Practice and Practice Economics Committee Member, Clinical Practice and Quality Management Committee Co-Founder and Board Member, Center for GI Innovation and Technology Chair, Coding and Payment Subcommittee Representative, AMA Relative Value Update Committee Representative, AMA CPT Advisory Panel Representative, AMA Practice Expense Review Committee Representative, AMA Physician Consortium for Performance Improvement Representative, AQA Alliance Representative, Physicians’ EHR Coalition Committee American Medical Association Vice-Chair, Practice Expense Subcommittee, Relative Value Update Committee Representative, Physician Consortium for Performance Improvement Representative, Office Based Surgery Work Group Representative, Infusion Coding Work Group Representative, Conscious Sedation Work Group Representative, Medication Therapy Management Services Work Group American Society for Gastrointestinal Endoscopy Member, Health and Public Policy Committee Member, Practice Management Committee American Society of Addiction Medicine Representative, AMA Relative Value Update Committee American College of Physicians Member, Subspecialty Advisory Group on Socioeconomic Affairs Co-Chair, Patient Centered Medical Home – Specialist Workgroup American Board of Quality Assurance and Utilization Review Member, Board of Directors Chair, Continuing Medical Education Committee Population Health Impact Institute Member, Board of Directors National Transitions of Care Coalition Member, Advisory Task Force Arizona Rural Health Association Vice President, President, Board of Directors GI Political Action Committee Member, Board of Directors National Council on Alcoholism and Drug Dependence Board of Directors University of Southern California School of Medicine Instructor in Medicine Community Memorial Hospital Chair, Department of Medicine Chair, Quality Improvement Committee Member, Pharmacy and Therapeutics Committee Member, Medical Staff Executive Committee Member, Utilization Review Committee Member, Risk Management Committee Ventura County Medical Center Director, Gastrointestinal Division Member, Department of Medicine Committee Member, Credentials Committee Member, Residency Training Committee |
| Medical / Professional |
|---|
| FELLOW: American College of Physicians American Gastroenterological Association American College of Gastroenterology American Society for Gastrointestinal Endoscopy |
Additional Experience
| Marketing Experience |
|---|
| Expert is Board Certified in Internal Medicine and Gastroenterology, and has practiced for over three decades in California and Arizona. He has assisted payor organizations, employers, physician groups and specialty societies develop and implement programs to improve patient care. Expert has held management positions with several managed care companies including Blue Shield of California and Prudential Health Care. He has worked extensively with the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) on coverage and reimbursement issues and, in 2005, served as the Co-Chair of the Part D medication measures Technical Expert Panel for CMS. |
| Other Relevant Experience |
|---|
| In 2004, the AMA presented the Burgess L. Gordon Memorial Award to Expert for outstanding service to the CPT process. |
Fields of Expertise
endoscope, gastroenterology, Current Procedural Terminology, medical coding, medical device coding, Medicaid, medical reimbursement, reimbursement, health care quality assurance, blue shield, utilization review, practice management, health care cost control, health care industry quality management, health care marketing, medical device, internal medicine, health care system