Expert Details

Expert in Healthcare, Medical Device, Diagnostics, Pharmaceuticals coding, reimbursement

Expert ID: 725000 Arizona, USA

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Expert, MD FACP AGAF FASGE FACG is a physician whose focus is strategy for coverage, reimbursement, quality improvement, bundled payments and accountable care.

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 FAIR Health, 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

Expert may consult nationally and internationally, and is also local to the following cities: Phoenix, Arizona - Tucson, Arizona - Mesa, Arizona - Glendale, Arizona - Scottsdale, Arizona - Chandler, Arizona - Tempe, Arizona - Gilbert, Arizona - Peoria, Arizona

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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 Responsibilities
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.
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.
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.
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
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.
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
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

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

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