2018 03 26 michael arrigo expert witness overview cv slides

Michael Arrigo
Expert Witness
No World Borders, Inc.
Experts in Healthcare Data, Regulatory and Economics

Bridging the business of medicine
with legal and medical teams

Expert Witness
Notable Engagements
1. U.S. Department of Justice (two retentions)
2. Anti-trust cases before Federal Trade Commission (two cases)
3. Class Actions involving HIPAA privacy and security and the HITECH
Act (four cases totaling over 11 million impacted patients)
4. Medical coding and billing disputes (20 cases)
5. Qui Tam False Claims Act (8 cases for relators, defendants, U.S.
attorney’s office)
6. Damages / loss calculations in malpractice, personal injury, and
fraud cases re: sentencing guidelines, actual and intended loss
7. Healthcare industry patent infringement litigation (5 cases)

Expert Witness Summary
• Knowledge training education and experience
• Notable Engagements
• Testimony never excluded in Federal or State Court
• Healthcare Market Segment Experience
• Example testimony and opinions topics (2 pages)
• Opinions regarding medical charges by various coding types and
payment models (inpatient, outpatient, pathology, devices, drugs)
• Healthcare data, regulatory and economic expertise

Expert Witness
Knowledge Training Education and Experience
• CEO of Healthcare Consulting Firm specializing in health data,
regulations, economics
• Publications – Peer Reviewed Published Articles
• Harvard Law School – Studies in Bioethics
• Stanford Medical School – Studies in Biomedical informatics
• University of Southern California – Degree, Business Administration
• University of California, Irvine – Computer Science, Economics
• Built a business from scratch - inception, venture funding and market
acceptance with hospital, health plan, pharmaceutical, medical device
and healthcare IT clients in 30 states
www.noworldborders.com/expert-witness/

Expert Witness
Professional Affiliations
• Medical Group Management Association (MGMA)
• Health Information Management Systems Society (HIMSS)
• American Academy of Professional Coders (AAPC)
• American Health Information Management Association (AHIMA)
• American Academy of Pain Medicine (AAPM)
• Workgroup for Electronic Data Interchange (WEDI)
• Association for Clinical Documentation Improvement Specialists (ACDIS)
• American Society for Clinical Pathology (ASCP)
• Information Systems Audit and Control Association (ISACA)
• National Alliance of Medical Auditing Specialists (NAMAS) (February 2018)
• Contributor: Strategic Financial Management Newsletter, Healthcare Financial Management Association;
• Prior contributor: Healthcare IT News, GovHealth IT, Mobile Health News, Financial Health News
• Volunteer: Children’s Hospital Medical innovation committee

Survived Motions to Exclude
(Testimony never excluded)
• Survived Daubert motion to exclude in Federal Court (motion denied)
• Survived Motion in Limine to exclude (motion denied)
• Survived Motion to exclude in Arbitration
• Declared as expert by Judge in litigation

Expert Witness
Healthcare Market Segment Experience
1. Hospitals
2. Critical Access Hospitals
3. Rural Hospitals
4. Federally Qualified Health Centers (FQHCs)
5. Integrated delivery network systems
6. Physician groups
7. Diagnostic imaging centers
8. Ambulatory surgery centers
9. Long-term case and home care
10. Accountable care organizations
11. Physician groups
12. Clinics, including dialysis centers, urgent care clinics
13. Payors / (aka payers) health plans

Expert Witness
Fraud, Damages, Error Rates, Meaningful Use, HIPAA
Privacy and Security, Medical Coding and Billing
1. Fraud documentation and patterns
2. Damages and loss calculations in fraud sentencing
3. Damages and loss calculations in payor provider disputes
4. Damages and loss calculations in provider v. billing company disputes
5. Damages usual customary and reasonable cost of medical charges in personal injury
litigation
6. Damages usual customary and reasonable cost of medical charges in medical
malpractice
7. Error rate and required sample sizes in loss calculation and damages analysis
8. Preponderance standard, population size, response distribution, error rate, or margin
of error, confidence level
9. Reasonable degree of certainty and sample size in damages and loss calculations

Expert Witness
Fraud, Damages, Error Rates, Meaningful Use, HIPAA
Privacy and Security, Medical Coding and Billing
10. Intended loss v. actual loss in Affordable Care Act sentencing guidelines
11. Fair market value compensation for medical directors
12. National and local coverage determinations as guidance on medical necessity
13. Meaningful use stimulus funds and recoupment in audits
14. Correlation of diagnosis complexity to billed procedures analytics
15. Medicare Secondary Payer Act charges and subrogation
16. Bundling and unbundling analysis using the National Correct Coding Initiative
(NCCI)
17. Risk adjustment models and HCC code groupings for Accountable Care and
Medicare Part C as methodology to value capitated payments to providers
18. Health care data standards with respect to generally accepted industry best
practices

Expert Witness
Medical Charges by Service, Device Type
1. Medical procedures charges using CPT, HCPCS, ICD-9 and ICD-10
PCS
2. Medical transportation charges via Ambulance using HCPCS coding
3. Medical devices, Durable Medical Equipment
4. Medical supplies using HCPCS
5. Facility fees by revenue code (operating room, recovery room, etc.)
6. Applicability of modifiers

Expert Witness
Data and Payment Models in Health Care
1. Inpatient prospective payment system (IPPS) and Diagnosis Related
Groupings (DRGs)
2. Outpatient Prospective Payment System (OPPS) and CPT codes
3. Ambulatory surgery centers – facility fee, procedures and physician fees
4. Physician fee schedules and CPT codes
5. Modifiers (e.g. technical component, professional component, same day
procedures, add-on codes, revenue codes)
6. Ambulatory Procedure Codes (APCs) and Ambulatory Surgery Centers
(ASCs)
7. Home Care Resource Group (HHRG) and point tabulations OASIS

Expert Witness
Health Insurance Coverage Determinations and Medical Necessity
Health Plans and Payer Policies Expert Witness
• Medicare National Coverage Determinations (NCDs)
• Medicare Local Coverage Determinations (LCDs)
• Medicare Administrative Contractors (MACs)
• Private payor coverage determinations
Coverage determination specifics
• Effective date
• Covered conditions
• Covered conditions ICD codes (9th or 10th version depending on date of service)
• Modifiers specified, if any
• Geography, if any
• Retired date (if applicable)

Expert witness
Healthcare Medical Specialties
1. National Correct Coding (NCCI) claims edits, Sept 2012.
2. Ambulance billing fees and trauma triage; State, Federal CDC trauma activation criteria Sept
2012
3. NAAC Certified Ambulance Coder (CAC) and Certified Ambulance Compliance Officer (CACO)
curriculum focusing on applying Clinical Protocols in the billing process, Billing for non-
transport, Medicare reimbursement policies and Non-Emergency authorization program.
4. Home health agencies HHRGs, OASIS episodes of care, Nov 2012
5. Behavioral health, November 2013
6. Cardiology, November 2013
7. Family practice and internal medicine, November 2013
8. Obstetrics, November 2013
9. Oncology, November 2013
10. Urology, November 2013

Expert witness
1. Orthopedics, November 2013
2. General Surgery, and Dental, November 2013
3. Plastic Surgery, November 2013
4. HCC, risk adjustment, November 2013
5. DRG calculations, ICD-10, IPPS, OPPS payment systems November 2013
6. Diagnostic Imaging & Nuclear Medicine (PET-Scans) September 2014
7. Medical Auditing, including focus on anesthesiology, pathology, evaluation
management, radiology, chemotherapy, psychotherapy, physical therapy,
modifiers, medical necessity. November 2015
8. Dermatopathology diagnosis relevant to medical specialty, 2016
9. Dietetics and Nephrology, insulin DME billing for diabetes, December 2015,
AHIMA

Expert witness
1. Liens, balance billing, subrogation seminar, 2014
2. Affordable Care Act ‘metal’ plans, Medicaid expansion, Federal Poverty Level guidelines on cost of care, 2014
3. Coding and reimbursement for Pain Management, December 2015; Outpatient physical, occupational, and speech therapy,
ambulance and non-emergency transportation, January 2016
4. Valuing episodes of Care: a) episodic, b) bundled payments, c) value-based payment / risk adjustments, d) episode groupers,
methodologies, e) PBM / pharmacy charges, f) costs associated with complications, g) prospective, retrospective, and
predictive modeling; h) claims adjudication in episodic processes, ACOs, MAOs, fiscal intermediaries, PROMETHIUS analytics
payment model for risk adjustment, comorbid factors and cohorts, data required to produce episodic care analysis; June 2016
5. Urology and toxicology screening guidelines training, In-Office Urine Drug Testing: Avoid Investigations and Audits, January 23,
2018
6.
Certified Professional Coder curriculum, 10,000 Series IntegumentarySystem February 25, 2018
7. Non-covered services and Advance Beneficiary Notices, GA, GZ, GX, GY modifier (not reasonable and necessary where ABN is
issued or statutorily excluded), February 28, 2018 Used in Medicare Part C (Medicare Advantage “MAO”) Accountable Care
(ACO) organizations
8. Training delivered by MD, board certified orthopedic surgeon who advised CMS in all 50 States
9. Training delivered by Radiology Certified Coder (RCC), Certified Interventional Radiology Cardiovascular Coder (CIRCC),
Certified Professional Coder (CPC) credentialed instructor

Expert Witness
Electronic Health Records Training and Experience
• Allscripts
• Cerner
• Epic
• Athenahealth
• Small E.H.R. companies
• Certifications of software by CMS / ONC approved Authorized Testing
groups including Drummond, ICSA
• Attestations for physicians and hospitals

Expert Witness
Health Care Processes Specific to Health Plans
1. Value-Based Care Reporting for Medicare Part C and Medicare Shared Savings Plan
Accountable Care Organizations, including: HEDIS, MSSP 33 measures, HCC coding, risk
adjustment, risk corridors, RADV and RAC audits, and compliance platforms.
2. EOB (Explanation of Benefits) — Advised health plans on the revisions in EOBs that must be
made to comply with new laws and regulations, such as ICD-10.
3. Actuarial & Underwriting — Mr. Arrigo and his team advised health plans on shifts in coverage
determinations and medical policy based on the Affordable Care Act, ICD-10, CORE Operating
rules, and other regulations.
4. Coverage determination planning and policy, and IT systems supporting new regulations
(including CMS Local Coverage Determinations and National Coverage Determinations).
Advised health plans and providers.
5. Claims processing metrics — Pass-through rates, manual vs. electronic claims adjudication,
and Utilization Management (UM) rates.
6. Payor — provider contracting — Mr. Arrigo leads a team that has over 30 years of health care
provider and health insurance contract negotiation experience for hospitals, clinics, and
diagnostic services providers.

Expert Witness
Health Care Processes Specific to Providers
• Readmissions metrics
• Clinical documentation, coding, encoders, and claims reimbursement
• Admission and discharge processes and metrics
• Revenue cycle management and metrics (DNFB – discharged not final
billed, etc.)

Expert Witness
Health Care Processes Specific to Providers
Patient intake
Patient assessment
Documentation of care
Insurance coverage determination
Discharge activities
Provider communications
Referrals
Prior authorizations
Coding
Charge capture, super bills
Billing
Revenue collection
Vendor impacts
EHR and other system readiness to support clinical documentation improvement
IT plans
Impact on concurrent initiatives
Reporting
Quality improvement efforts
Payor readiness and processes; medical policy assumptions for contracting
Institutional Review Board (IRB) impact review for ICD-10
Data warehouse and business intelligence “retooling” of analytics required.
National Correct Coding Initiative (NCCI), Modifiers, Bundling and Unbundling
Criteria According to Centers for Medicare and Medicaid

Expert Witness
Medicaid, Social Security, Insurance Exchange, Benefits Determination
Information Architecture:
• Medicaid Information Technology Architecture (MITA) initiative,
sponsored by the Center for Medicare and Medicaid Services (CMS),
is intended to foster integrated business and IT transformation across
the Medicaid enterprise to improve the administration of the
Medicaid program. Led engagements to extend and enhance
Medicaid systems with enterprise software partners in several States
prior to, during, and immediately after the MITA Architecture update
to accommodate HIPAA 5010, ICD-10, the Affordable Care Act,
HITECH Act, CHIPRA, and NCPDP standards.

Expert Witness
• Types of Exchanges and Enrollee Characteristics:
• Federal (HHS) Exchanges “Federally-Facilitated Marketplace” (“FFM”)
which are being used in States, such as: (FL, GA, NC, SC, VA, AL, MS,
MO, AR, LA, OH, PA, IL, OK, MT, UT, ND, SD, NE) and provider
contracting.
• State-Based Exchange (“SBEs”) and State-by-State variances (CA, WA,
ID, CO, KY, MN, NY, VT, RI, CT, MA, DE, MD, DC).
• State MMIS – Medicaid Management Information Systems, which
provide some of the eligibility technology platform for the Exchanges.

Expert Witness
Eligibility Process, Technology for State Health and Public Welfare
• Request for insurance, pre-existing conditions under Affordable Care Act
• 42 CFR MAGI – Modified Adjusted Gross Income (U.S. Citizenship, criminal and State Residency,
household size and FPL % [see FPL])
• FPL percentage – percent of Federal Poverty Level
• TANF – Temporary Assistance to Needy Families (formerly AFDC)/The Personal Responsibility and
Work Opportunity Reconciliation Act of 1996 (Public Law 104-193) and TEFRA
• SNAP – Supplemental Nutrition Assistance Program (formerly food stamps)
• Medicaid – free and low-cost healthcare to low-income families
• CHIP – Children’s Health Insurance Program (Medicaid for kids)
• Women, Infants & Children (WIC) – nutritional supplement for pregnant women, infants, and
children (until school age)
• Section 1619(b) of the Social Security Act re: Social Security beneficiaries, Medicaid eligibility.

Expert Witness
HIPAA Privacy Rule and Security Rule
Security best practices for HIPAA Covered Entities
• HHS Security Standards:
• Administrative Safeguards
• Physical Safeguards
• Technical Safeguards
• Organizational Policies and Procedures and Documentation
Requirements

Expert Witness
HIPAA Privacy Rule and Security Rule
• “Breach” under the Privacy Rule, including but not limited to, 45 C.F.R. § 164.402.
• “Business Associate” under the Privacy Rule, including but not limited to, 45 C.F.R. § 160.103.
• “Covered Entity” under the Privacy Rule, including but not limited to, 45 C.F.R. § 160.103.
• “Designated Record Set” under the Privacy Rule, including but not limited to, 45 C.F.R. § 164.501.
• “Disclosure” under the Privacy Rule, including but not limited to, 45 C.F.R. § 160.103.
• “Electronic Protected Health Information” or “ePHI” under the Privacy Rule, including but not limited to, 45 C.F.R. § 160.103.
• “Individual” under the Privacy Rule, including but not limited to, 45 C.F.R. § 160.103.
• “Minimum Necessary” under the Privacy Rule, including but not limited to, 45 C.F.R. §§ 164.502(b) and 164.514(d).
• “Privacy Rule” Standards for Privacy of Individually Identifiable Health Information at 45 C.F.R. Part 160 and Part 164, Subparts A and E.
• “Protected Health Information” or “PHI” in 45 C.F.R. §§ 160.103 and 164.501, and is the information created or received by BA
• “Required by Law” in 45 C.F.R. § 164.103.
• “Security Incident” shall have the meaning given to such term under the Security Rule, including but not limited to, 45 C.F.R. § 164.304.
• “Security Rule” 45 C.F.R. Part 160 and Part 164, Subparts A and C.
• “Subcontractor” under the Privacy Rule, including but not limited to, 45 C.F.R. § 160.103.
• “Unsecured Protected Health Information or PHI” under the Privacy Rule, including but not limited to, 45 C.F.R. § 164.402.
• “Use” under the Privacy Rule, including but not limited to, 45 C.F.R. § 160.103.

Expert Witness
Electronic Health Records
• Authorized Testing and Certifications Bodies (ATCBs) and processes.
• Eligible Hospital (EP) and Eligible Provider (EP) attestations and audit defense under Medicare and Medicaid in civil and criminal
defense cases.
• Data quality check on numerators and denominators in live data vs. attestation reporting.
• Stimulus funds, OIG, and CMS auditors.
• HHS OCR, HIPAA breaches, State CMIA breaches, and stimulus eligibility.
• Modular and Complete E.H.R. certifications.
• Discrete data structures.
• HIPAA Privacy and Security Assessments as a Component of MU and the Administrative, Physical, and Technical Safeguards of
HITECH Act as well as Operational Policies, Procedures and Documentation, and HIPAA overlapping requirements.
• Clinical workflow for both acute care and ambulatory E.H.R.s.
• Rollout Phase I, II of E.H.R. implementation in Emergency and Radiology departments.
• Medication dispensing modules.
• Standardized the implementation process and used as quality control while contracted to U.S. HHS/ONC to educate Regional
Extension Centers providing national education and quality standards that were adopted by ONC.

Expert Witness
Patent Litigation Experience
• Mobile health
• Software licensing in healthcare IT solutions distribution
• Electronic health records
• Physician productivity
• Healthcare analytics
• Healthcare claims data
• Medical coding
• Medical coding encoders and computer assisted coding (CAC)

Expert Witness
Healthcare / HIPAA Transactions for Electronic Data Interchange (EDI)
• Health Care Eligibility Benefit Inquiry and Response – EDI 270/271
• Health Care Claim Status Request/Response – EDI 276/277
• Health Care Services Request for Review/Response (Prior Auth.) – EDI 278
• Payroll deductions for premiums – EDI 820
• Benefit enrollment and maintenance – EDI 834
• Health care claim: Payment/Advice – EDI 835,
• Health Care Claim: institutional, professional / dental –
• EDI 837, Pharmacy claim (NCPDP),
• Coordination of Benefits (COB) and third-party liability
• Fraud waste and abuse analytics and Special Investigative Unit (SIU)
• Modifications to § 162.1102, § 162.1202, § 162.1302, § 162.1402, § 162.1502, § 162.1602, §
162.1702, and § 162.1802 to adopt the ASC X12 Technical Reports Type 3 (TR3), Version 005010
(Version 5010) reporting of clinical data, enabling the reporting of ICD–10–CM diagnosis codes
and ICD–10–PCS procedure codes

Locations:
Portal to Portal
fees from location
nearest to the
venue
Seattle
4205 S.E. 36th St.
Bellevue WA 98006
1 (206) 407-3865
Denver
600 17th Street
Suite 2800 South
Denver, CO 80202
1 (720) 726-9867
Chicago
200 East Randolph Street
Chicago, IL 60601
1 (312) 278-3207
Boston
Ten Post Office Square
8th Floor
Boston, MA 02109
1 (617) 231-7002
San Francisco
Four Embarcadero
Suite 1400
San Francisco, CA 94111
1 (415) 653-8933
Salt Lake City
175 S Main Street
Salt Lake City, UT 84111
1 (801) 893-9054
St. Louis
1033 Corporate Square Drive
St. Louis, MO 63132
1 (314) 366-4912
New York
575 Madison Avenue
New York, NY 10022
1 (646) 661-5516
Silicon Valley
2225 East Bayshore Road
Suite 200
Palo Alto, CA 94303
1 (650) 690-2196
Dallas
3030 LBJ Freeway, Suite 700
Dallas, TX 75234
1 (214) 295-6028
Pittsburgh
600 Grant Street
Suite 660
Pittsburgh, PA 15219
1 (412) 230-8432
Headquarters
Los Angeles, Orange County
620 Newport Center Drive
Suite 1100
Newport Beach, CA 92660
1 (949) 335-5580
Washington, DC
5335 Wisconsin Avenue NW
Washington, DC 20015
1 (202) 792-4980
San Diego
12526 High Bluff Drive
San Diego, CA 92130
1 (858) 242-4016
Atlanta
235 Peachtree Street NE
Suite 400
Atlanta, GA 30303
1 (678) 331-5506
Honolulu
1888 Kalakaua Avenue, C312
Honolulu, HI 96815
1 (808) 664-1939
Miami
1395 Brickell Ave.
Suite 800
Miami, Florida 33131
1 (305) 615-2390

Expert Witness
More information
www.noworldborders.com

2018 03 26 michael arrigo expert witness overview cv slides

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to 2018 03 26 michael arrigo expert witness overview cv slides

Similar to 2018 03 26 michael arrigo expert witness overview cv slides (20)

More from Michael Arrigo

More from Michael Arrigo (7)

Recently uploaded

Recently uploaded (20)

2018 03 26 michael arrigo expert witness overview cv slides