Emily Petersen

Prior to joining Ankura, Emily previously worked at a Fortune 200 HMO coordinating inpatient, outpatient, home health, ambulance transport, and hospice benefits for both Medicare and Commercial members as a regional manager of Utilization Review. She was a certified Inter Qual™ instructor and had responsibility for all training of regional medical management clinicians in the principles of medical necessity and utilization review criteria. Her background in bedside nursing includes participation in clinical research trials and staff training at hospitals affiliated with Yale University School of Medicine and Harvard Medical School. 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.

Recent engagement highlights include:

• Testifying expert in a confidential arbitration matter related to claims adjudication in the setting of specialized coding and reimbursement policies, and preparation of an expert report on clinical necessity and billing requirements for certain types of diagnostic testing
• Conducting long-term reviews for acute-care facilities under a Corporate Integrity Agreement from the OIG. She has participated in meetings with the Department of Justice 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. Additionally, she has worked with facilities to improve controls and reporting to state Medicaid and Medicare agencies and instituting workflows ensuring future compliance.
• The types of matters Emily has been involved with include: long term acute care lengths of stay (LTAC), medical necessity reviews of internal cardioverter defibrillators (ICDs) and PTCA/stents, one-day stays, skilled nursing, adult and geriatric psychiatry, due diligence reviews, concurrent surgery reviews, and the off-label promotion of drugs. She is adept in the use of Inter Qual and Milliman Care Guidelines.

In addition, Emily is a Certified Risk Adjustment Coder (CRC) with expertise in reviewing medical records and assigning accurate medical codes for services provided by physicians and other healthcare providers in the office or facility setting. She has worked with large Medicare Advantage plans and provider groups in conducting internal audits. Emily has a strong understanding of RADV, the audit process for risk adjustment models and determining correct HCC assignment. Additionally, she has successfully identified and communicated documentation deficiencies to providers to identify opportunities to improve documentation for accurate risk adjustment coding.

• Emily is certified in Healthcare Research Compliance (CHRC) and has assisted in the management of internal research misconduct investigations in partnership with internal and external counsel. She has experience in the application of relevant controls to ensure compliant billing and in clinical trial billing analysis. In addition, Emily has provided significant operational support to research organizations, health systems, and hospitals by assessing their research function and associated procedures for compliance.