John Stearns is a managing director in the Healthcare and Life Sciences Disputes, Compliance, and Investigations practice. He specializes in providing financial, economic, investigative, clinical, operational, and industry expertise assistance to health sciences providers, payers, physicians, and the health law community. With more than 20 years of progressive management experience in acute and post-acute care, he is well versed in Medicare reimbursement, fraud and abuse issues, and ancillary operations.
John’s work experience includes developing complex financial models and analyzing large volumes of coding, billing, and reimbursement data in a wide variety of industry areas, including direct patient care providers, DME suppliers, and other service providers. He has also led independent review organization engagements involving large scale medical records sampling and review for patient care providers and a third-party billing company. He has provided expert testimony in disputes relating to charge structure, contract therapy services, regulatory practices, and medical necessity of services in a skilled nursing facility.
Select engagement experience includes:
- Engagement director for a review of hospice general inpatient level of care claims following the OIG self-disclosure protocol. The results were used to support the submission of a several million dollar overpayment.
- Engagement director for several compliance and operational reviews related to a third party’s acquisition of home health, skilled nursing facility, hospice, and long-term acute hospital providers. Compliance reviews focused on internal compliance controls and testing of billing and coding compliance with patient assessment instruments and medical record documentation. Hospice specific analyses related to documentation compliance controls (including benefit election and initial plan of care) and level of care classification. The results were used to strengthen compliance-related policies and procedures.
- Engagement director for a review of inpatient rehabilitation facility claims subject to Medicare Administrative Contractor and Recovery Audit Contractor audits. In addition to analyzing technical requirements of IRF documentation, the medical necessity of admission for claims requested by the MAC and RAC were analyzed, as well as claims that were held by the provider. We also analyzed a full year of diagnosis codes submitted as part of the annual 60% threshold process to determine if diagnosis codes were in fact billed correctly.
- Engagement director for several independent review organization engagements according to Corporate Integrity Agreement requirements for a number of provider types, including skilled nursing facilities, acute care hospitals, retail pharmacy, physician third-party billing company, durable medical equipment (wheelchairs)
- Engagement director for billing and compliance reviews for a company’s acquisition of durable medical equipment operations that included oxygen and oxygen equipment, wheelchairs, enteral nutrition, and traditional DME products, such as nebulizers, assistive devices, and hospital beds
- Engagement director for an annual review of billing and coding compliance for orthopedic devices, bone growth stimulators, and TENS devices
As a licensed physical therapist, John has practical work experience in the acute hospital setting, including inpatient and outpatient rehabilitation, brain injury rehabilitation, and intensive care.