Industries & Practices

Provider & Medical Staff Issues

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Medicare/Medicaid Fraud & Abuse
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New rules in Ohio affecting consult agreements with pharmacists

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Medical staff

Worked closely with medical staff leadership for health system with separate medical staffs on credentialing, privileging, professionalism and effectiveness, quality and peer review matters for medical staffs, GME residents/fellows and advance practice providers. 

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Medical staff bylaws and governance

Managed and developed medical staff bylaws and governing documents for multi-hospital health system with separate medical staffs to standardize the processes and bylaws language for credentialing, privileging, peer review and corrective action across the system.

Advised and worked closely with medical staff leadership to conduct reviews of medical staff governing bylaws, rule and regulations, policies and procedures for compliance with Medicare conditions of participation, applicable law and private accreditation standards (i.e., TJC, HFAP, DNV/NIAHO) making recommendations for standardization and industry best practices.

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Medical staff bylaws overhaul

Complete redraft of medical staff bylaws, rules and regulations, credentialing, peer review and fair hearing policies for a large health system with separate medical staffs.

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Graduate Medical Education (GME)

Worked closely with teaching faculty and hospital leadership for academic medical center with over 100 training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Advised and conducted reviews of hospital and GME policies and procedures for sponsoring institution and program compliance with Medicare conditions of participation and ACGME requirements. Developed and negotiated affiliation agreements and program letters for education and clinical training of residents and fellows.

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Peer review and medical staff hearings

Developed peer review processes for separate medical staffs and practitioners granted clinical privileges for a health system in order to promote consistent standards of care throughout the system.

Represented health system in fair hearings and appeals regarding adverse recommendations of medical staff appointments and/or clinical privileges for medical staff members.

Developed a peer review process for physicians and practitioners employed by hospital-affiliated entities and created documents that permitted the sharing of peer review information between the health system hospitals and the affiliated entity.

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Credentials Verification Organizations (CVO) and Managed Care

Represented a large health system for initial and maintenance of National Committee for Quality Assurance (NCQA) CVO certification. Developed and negotiated delegated credentialing agreements on behalf of CVO and health system with multiple CMS Certification numbers with 30+ managed care plans. Advised and represented CVO and health system with multiple CMS Certification numbers on credentialing and CVO policies, enrollment and appeals of participating providers.

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Hospital transition to orthopedic-only center

Assisted a health system in transitioning a hospital campus into a specialty services center, which required engaging physicians on the center’s medical staff to participate in quality improvement and cost reduction efforts. Developed, negotiated and prepared legal structure and contractual arrangements for the health system to engage physicians and ensure compensation at fair market value for these efforts.

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Medical staff bylaws overhaul

Redrafted a large hospital system’s medical staff bylaws, rules and regulations and organization manual, which contained the committee structure, sharing of information and peer review processes. The system’s medical staff documents and processes are now standardized, allowing for increased sharing of quality and performance data within the system and improved patient care.

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Medical staff unification

Unified a health system’s three medical staffs to be in compliance with the Centers for Medicare and Medicaid Service’ Conditions of Participation to create increased efficiencies within the system’s hospitals. Restructured the unified medical staff’s peer review process and rules and regulations.

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Medical staff fair hearing

Represented a medical center in a fair hearing regarding the denial of a physician’s application for medical staff appointment and clinical privileges. We successfully convinced the hearing officer of the accuracy of the medical executive committee’s recommendation to deny the physician’s applications, given documented instances of substantial professional behavioral issues.

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