Emily Petersen

Emily is frequently called upon to perform highly detailed documentation, claims, and policy reviews. She has a deep understanding of the clinical review strategies and unique considerations in Medicare Severity, All Patient, and Severity / All Patients Refined Diagnosis Related Group methodologies. Emily also has expertise in the analysis of medical record documentation with a focus on the level of severity and complexity of individual cases based on ICD-10/CPT/HCPCs coding guidance, and reviewing the entirety of the record against relevant requirements.

Emily’s clinical experience is rooted in hands-on nursing, including participation in clinical research trials and training at academic medical centers. Her background in critical care nursing includes participation in staff development and training at hospitals affiliated with Yale University School of Medicine and Harvard Medical School, where she worked in the coronary intensive care unit and diagnostic imaging. She engaged in critical care nursing for cardiac, neurologic, major surgery, chronic medical, and hospice patients while assisting medical and surgical staff during invasive procedures.

Emily’s role as a CRC involves the precise review and coding of medical records for national Medicare Advantage plans and provider group audits. Her past experience also includes coordinating comprehensive healthcare benefits as a regional manager of care management for a Fortune 200 health maintenance organization, where she also served as an InterQual™ Instructor, training clinicians in medical necessity and utilization review criteria. She has extensive experience managing internal research misconduct investigations alongside both internal and external counsel. She has a proven track record in applying necessary controls for compliant billing, particularly in the context of clinical trial billing analysis.

Recent engagement highlights include:

• Management of multiple documentation, coding, and billing audits for health systems and physician practices, some of whom were under civil and/or criminal investigation by the Office of Inspector General (OIG) and Department of Justice (DOJ). Assisted clients and counsel in identifying areas of deficiency and related risk, implementing controls, and developing facility-specific training for providers.
• Lead clinical reviewer during DOJ-initiated ICD investigation for over 50 hospitals; performed review of relevant medical records for over 5,000 implantations. Provided detailed written summaries and reports to internal and external counsel and worked with executive leadership to institute workflows to ensure future compliance.
• Participation in meetings with the DOJ on behalf of clients being investigated under the False Claims Act and assisted counsel in the preparation and delivery of voluntary disclosures and refunds to the government.
• Engagement lead for an independent review organization assisting an acute inpatient hospital client, conducting department reviews in accordance with Corporate Integrity Agreement requirements. Areas of review included risk assessment, compliance program assessment, and specific medical record reviews. Directed the completion of annual reports provided to the compliance officer and OIG.