601 NW 22 nd Court Wilton Manors, FL 33311 Phone: (954) 610-381 PROFESSIONAL SUMMARY I am a hospitalist of 18 years with an extensive background in quality improvement, utilization review, information technology and multiple EHR platforms including Clintegrity, Dragon, Midas, Cerner, Epic and Meditech. I have extensive experience with case management and revenue cycle functions including medical necessity, billing and coding denials and audits (including the OIG) at both the government and private payer levels. I am well versed in implementing compliant documentation programs that have a significant impact on quality metrics and value based purchasing initiatives in both the hospital and office setting. I have broad experience identifying liabilities inherent in EHR s on patient safety and care as well as revenue cycle functions. I am adept at building and leading high-performing quality teams to implement change. PROFESSIONAL EXPERIENCE J.A. Thomas: A Nuance Communications Division Company, Atlanta, GA Regional Medical Director (July 2013 to present) - Consultant: Medical Staff/Leader Engagement in Clinical Documentation Improvement (CDI) and ICD-10 Preparation - Physician Educator: Documentation in ICD-9/ICD-10 coding to capture Medical Necessity & Severity of Illness, to support regulatory compliance; - CMO/Medical Director Support: Documentation of Present on Admission (POA) vs. Healthcare Acquired Conditions (HAC) to support compliance and quality reporting; - Health IT Advisor: Computer Assisted Coding & Other Computer Assisted Technologies to support documentation, outcomes, EHR compliance as well as ICD-10 preparation; - Recognized Speaker: Health Care Reform, ICD-10, Medicare/Medicaid. Managed Care, Values-Based Purchasing in Healthcare, Clinical Documentation & Its Revenue Cycle Impact
2 AppealMasters/Intersect Healthcare, Lutherville, MD Chief Physician Advisor (June 2013 to present) - Conduct retrospective medical record audits, evaluate and determine suitability of cases for appeal, author letters of appeal, representing nationwide client hospitals and health care systems during hearings with the Administrative Law Judges of the Office of Medicare Hearings and Appeals. - Responsible for conducting thorough reviews of hospital medical records from claims previously denied payment by commercial payers, documenting the services provided, and formulating a concise summary of the case based on ERISA statutes or relevant federal and state insurance regulations and an appeal argument based on the medical necessity of the care provided. Clients have included large University Health Systems, national multi-state for profit healthcare systems as well as critical access hospitals. - Provide onsite and webinar based denials management training for client hospitals including one of the healthcare industry's leading national providers of business and operational services. - Provide root-cause analysis to identify facility specific patterns of denials and communicate these findings to the relevant physicians and medical staff for action as well as interacting with hospital IT departments to suggest improvements to the EHR to strengthen documentation and eliminate inconsistencies in EHR templates that are often used as a basis for denial of care. - Communicate up to date NCD s and LCD s (national and local coverage determinations) to client hospitals to minimize MAC pre-payment denials MedStar Washington Hospital Center, Washington, D.C. Physician Advisor, Clinical Resource Management (June 2011- June 2013) Acute Inpatient/Care Management Functions Managed the response to the Recovery Audit Program (RAC), Medicare Administrative Contractors pre-payment audit program (MAC) as well as a comprehensive OIG facility audit (authored in excess of 3,000 responses to denials and claims made by RAC, MAC, and the OIG). Reviewed medical records of patients identified by care managers or as requested by the healthcare team in order to: Assist with level of care and length of stay management Assist with the denial management process Review and make suggestions related to resource and service management
3 Assist staff with the clinical review of patients Determine if professionally recognized standards of quality care are met Provided feedback to attending and consulting physicians regarding level of care, length of stay, and quality issues Recommended and requested additional, more complete, medical record documentation. Recommended next steps in coordination of care and evidence-based medicine indicators. Reviewed cases that indicate a need for issuance of a hospital notice of noncoverage/important Message from Medicare. Discussed the case with the attending physician and if additional clinical information is not available, discussed the process for issuance and appeal to the physician. Documented patient care reviews, decisions, and other pertinent information. Understands and uses InterQual and Milliman and other appropriate criteria. Documented response to case management referrals. Supported Care Management in a data-driven approach. Notified the care manager of any conflict of interest in reviewing a particular patient record. Assisted in dentifying a physician to review such record. Acted as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate. Facilitates, mentors, and educated other physicians regarding payer requirements. Participated in review of long stay patients, in conjunction with the Care Management Leadership, Care Management Team and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care. Participated in patient rounds with the Healthcare Team as indicated. Identified patients who were appropriate for transfer to LTACH facilities and worked with physicians to facilitate referrals as needed. Provided guidance to ED physicians and ED Care Management regarding status issues and alternatives to acute care when acute care was not warranted. Worked with Care Management and an interdisciplinary team to ensure appropriate continuity of care and to reduce readmissions. Physician Support and Education Provided education to physicians and other clinicians related to regulatory requirements, appropriate utilization, alternative levels of care, community resources, and end of life care. Works with physicians to facilitate referrals to the continuum of care. Assisted physicians with end of life and hospice care consultations when appropriate.
4 Provided education to physicians and other clinicians regarding inappropriate admissions to the ICU and Created working groups to develop action plans to address these patients. Hospital Process Improvement Identified quality, safety, patient satisfaction and efficiency issues leading to suboptimal care. Supported the organization in quality improvement efforts requiring physician input and/or involvement. Clinical Documentation Support Educated individual hospital staff physicians about ICD-9 and ICD-10 coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records. Educated specific medical staff departments (e.g., Internal Medicine, Surgery, Family Practice, etc) at departmental meetings regarding: Reasons why individual physicians should be concerned about correct disease reporting and the subsequent ICD code capture of severity, acuity, risk of mortality, and DRG assignment, such as: Physician performance profiling, Physician E&M payment and pay for performance. Appropriate hospital reimbursement and profiling for patient care. Ways to provide improved health record documentation that specifically affect ICD code assignment capture of severity, acuity, risk of mortality, and DRG assignment. Medical Informatics Support Worked with the Cerner based EHR team to ensure the system appropriately supported the physician s ability to provide best- practice medicine by creating logical processes and developing the necessary order sets and practice guidelines. Participated in physician education and outreach efforts. Worked in collaboration with the IT team to be sure all necessary physicians are trained and training is appropriate for the physicians. Participated as part of the physician advisory council to assist IT with clinical decisions for the EHR. Assisted with order set development, review, and implementation to coordinate quality, efficiency, and utilization of order sets and templates.
Cleveland Clinic Hospital, Weston, Florida (November 2004 May 2011) R. Kendall Smith, Jr., MD, SFHM 5 Director, Section of Hospital Medicine - Developed a new academic hospitalist program within the Division of Internal Medicine including hiring and development of policies, procedures and scheduling - Developed curriculum to educate residents and medical students in the core concepts of hospital medicine - Teaching and supervision of medical residents, medical students and other allied health professionals (nurse practitioners, clinical pharmacists) - Chairman of the Pharmacy and Therapeutics Committee. Roles included o Working with the Director of Pharmacy Services for the development and implementation of systematic policies and procedures for medication use. o Collaboration with the Director of Pharmacy Services for the development and implementation of a Formulary of Approved Drugs at the Cleveland Clinic Hospital including: 1. formulary restrictions 2. formulary guidelines 3. drug use algorithms o Acted as liaison between attending physicians and house staff in all matters relating to medication use at the Cleveland Clinic Hospital, Weston Florida. - Implementation team for transition to EPIC EMR including CPOE - Director, Utilization Review/Case Management o Advised, assisted and educated treating physicians, hospital case managers, senior medical management, administration and all others involved in the delivery of timely appropriate and cost effective care. o Conducted verbal and written review and appeal of denied or downgraded coverage determinations made by managed care/commercial payors. o Facilitated communication between managed care/commercial payors and providers regarding benefit coverage issues, utilization review and quality assurance processes.
6 - Identified the need for and implemented a clinical documentation improvement program - Implemented an Epic based EHR ensuring the system appropriately supported the physician s ability to provide best- practice medicine by creating logical processes and developing order sets and templates based on professional society guidelines to ensure patient safety and quality outcomes. - Winchester Hospital, Winchester, MA (2002-2004) Director, Section of Hospital Medicine - Developed a new community based hospitalist program within the Division of Internal Medicine including hiring and development of policies, procedures and scheduling Central Florida Hospitalist Partners, Orlando, FL (1999-2002) President, Founding Partner - Founding member of a multi-hospital 12 member hospitalist group providing inpatient acute care across 4 community hospitals and 2 tertiary care centers in the greater Florida area. Orlando Regional Healthcare, Orlando, FL (1997-1999) Assistant Medical Director, Department of Internal Medicine - Teaching and supervision of medical residents, medical students and other allied health professionals (nurse practioners, clinical pharmacists) University of Florida, VAMC, Gainesville, FL (1996-1997) Clinical Instructor, Department of Internal Medicine - Teaching and supervision of medical residents, medical students and other allied health professionals (nurse practitioners, clinical pharmacists) EDUCATION Residency, Internal Medicine, July 1994 - July1996 University of Florida, Gainesville, Florida
7 Internship, Internal Medicine, July 1993 July 1994 University of Florida, Gainesville, Florida Doctor of Medicine, May 1993 Wayne State University, Detroit, MI University of Michigan 1989-1993 Ann Arbor, MI Biology Major PROFESSIONAL AFFILIATIONS/CERTIFICATIONS: Society of Hospital Medicine Senior Fellow in Hospital Medicine (2010) American College of Physicians American Medical Association Florida Medical Association American College of Physician Advisors CERTIFICATION/LICENSURE: AHIMA ICD-10 CM/PCS Certified Trainer/Ambassador Board Certified in Internal Medicine (current through 2017) Active medical licenses in Florida and the District of Columbia Unrestricted DEA license including schedules 2, 2N, 3, 3N, 4.5 HONORS/AWARDS: Senior Fellow Hospital Medicine, Society of Hospital Medicine (2010) Jose Muniz MD Teaching Award, Cleveland Clinic Florida (2005)
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