Agenda | Kisaco Research

Agenda

2nd Annual Healthcare Payment & Revenue Integrity East
22-23 May, 2024
The Westin Copley Place, Boston

Meet the PI leaders

Payment integrity leaders and emerging experts from the leading health plans on the East coast will be coming together this May to share their insights on the trends and challenges of the market.

To view the full line-up view the agenda below or click here.

Author:

Cathy Newman

Managing Director Value-Based Strategy
Blue Cross Blue Shield of Rhode Island

Cathy Newman is the Managing Director of Value-Based strategy for Blue Cross Blue Shield of Rhode Island.  Her experience in the healthcare industry spans over twenty years working for both large integrated providers, small IPAs, and health plans.  In her ten years with Blue Cross, she has worked to advance value-based opportunities from pay for performance to full-risk global capitation models.  She is passionate about her work and has been able to develop more collaborative and meaningful relationships with providers throughout the state of Rhode Island.

... read more

Cathy Newman

Managing Director Value-Based Strategy
Blue Cross Blue Shield of Rhode Island

Cathy Newman is the Managing Director of Value-Based strategy for Blue Cross Blue Shield of Rhode Island.  Her experience in the healthcare industry spans over twenty years working for both large integrated providers, small IPAs, and health plans.  In her ten years with Blue Cross, she has worked to advance value-based opportunities from pay for performance to full-risk global capitation models.  She is passionate about her work and has been able to develop more collaborative and meaningful relationships with providers throughout the state of Rhode Island.

Author:

Monique Pierce

Head of Payment Integrity
Devoted Health

Monique is a Strategic Executive Healthcare Leader with proven ability to develop solutions and maximize the benefits of Payment Integrity programs.  She is known for having excellent domain knowledge and being driven, high performing, and having a deep dedication to recruiting and developing top talent.

 

Monique started her Payment Integrity career at Oxford HealthPlans in the COB and Subrogation Department after spending time in Payment Policy.  When United Healthcare acquired many health plans in the early 2000s like Oxford, Monique was tagged as part of the Optum team to integrate the processes and people into the COB systems that she had built at Oxford.  She led systems development, quality, reporting, operations, vendor management and was responsible for creating innovative proactive programs that more than doubled savings to $1.4B in three years.

 

Monique developed a successful program that reduced interest expense on late claims for UHC, assisted a communication company to develop COB tools and assisted in strategic system projects before joining SCIO Health Analytics in 2014 to develop new products - specifically prepayment programs.

In 2015 she became the product owner of SCIOMine, the company’s internal audit application and managed the roadmap.  Monique also owned

strategic direction for operational metrics and reporting including executive scorecards. Monique was promoted to VP of Business Opportunities and Client Engagement where she improved Audit Recovery TAT by 39% and reduced client implementations TAT by 11% and the Level of Effort by 18% while increasing the count of implementation projects by 126%.

 

In 2020 Monique joined Devoted Health, a startup company with the goal of building the first ever integrated Payment Integrity Program.  The company has one system, great data, and a great mission; to change health care by treating every member as if they are family.

 

In her spare time, Monique volunteers her time in the community on the Board of Directors of SCARE NH and works in her family business LARP Portal with her husband Rick.

... read more

Monique Pierce

Head of Payment Integrity
Devoted Health

Monique is a Strategic Executive Healthcare Leader with proven ability to develop solutions and maximize the benefits of Payment Integrity programs.  She is known for having excellent domain knowledge and being driven, high performing, and having a deep dedication to recruiting and developing top talent.

 

Monique started her Payment Integrity career at Oxford HealthPlans in the COB and Subrogation Department after spending time in Payment Policy.  When United Healthcare acquired many health plans in the early 2000s like Oxford, Monique was tagged as part of the Optum team to integrate the processes and people into the COB systems that she had built at Oxford.  She led systems development, quality, reporting, operations, vendor management and was responsible for creating innovative proactive programs that more than doubled savings to $1.4B in three years.

 

Monique developed a successful program that reduced interest expense on late claims for UHC, assisted a communication company to develop COB tools and assisted in strategic system projects before joining SCIO Health Analytics in 2014 to develop new products - specifically prepayment programs.

In 2015 she became the product owner of SCIOMine, the company’s internal audit application and managed the roadmap.  Monique also owned

strategic direction for operational metrics and reporting including executive scorecards. Monique was promoted to VP of Business Opportunities and Client Engagement where she improved Audit Recovery TAT by 39% and reduced client implementations TAT by 11% and the Level of Effort by 18% while increasing the count of implementation projects by 126%.

 

In 2020 Monique joined Devoted Health, a startup company with the goal of building the first ever integrated Payment Integrity Program.  The company has one system, great data, and a great mission; to change health care by treating every member as if they are family.

 

In her spare time, Monique volunteers her time in the community on the Board of Directors of SCARE NH and works in her family business LARP Portal with her husband Rick.

Author:

Drew Satriano

Vice President of Payment Integrity
Highmark Health
... read more

Drew Satriano

Vice President of Payment Integrity
Highmark Health

Author:

Michael Devine

Director Special Investigations Unit
L.A Care
... read more

Michael Devine

Director Special Investigations Unit
L.A Care

Author:

Danielle Nelson

FWA Program Manager
PacificSource Health Plan
... read more

Danielle Nelson

FWA Program Manager
PacificSource Health Plan

Author:

Conor McCauley

Director, Payment Integrity Clinical Capabilites
Highmark Health

My name is Conor McCauley. I am the Director of Payment Integrity Clinical Capabilities at Highmark. Being a Critical Care nurse, it is easy to see there are issues surrounding healthcare funding. Inserting clinical insights into reimbursement methodologies can lead to affordability and improved patient outcomes. Clinicians are well positioned to make a difference here. My passion is developing an engaged team, effective processes, and surrounding clinicians with the right technology, data, and market insights so they can work at the top of their licensure.

... read more

Conor McCauley

Director, Payment Integrity Clinical Capabilites
Highmark Health

My name is Conor McCauley. I am the Director of Payment Integrity Clinical Capabilities at Highmark. Being a Critical Care nurse, it is easy to see there are issues surrounding healthcare funding. Inserting clinical insights into reimbursement methodologies can lead to affordability and improved patient outcomes. Clinicians are well positioned to make a difference here. My passion is developing an engaged team, effective processes, and surrounding clinicians with the right technology, data, and market insights so they can work at the top of their licensure.

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Printable version

Wednesday, 22 May, 2024
09:00
  1. Gain insights into the effects of regulatory changes on payment and revenue integrity operations.
  2. Learn the impact of innovations, such as automation, on the work of these organisations and how they will improve processes.
  3. Discuss strategies for cost containment while still accounting for the need to reduce provider abrasion in the evolving regulatory landscape.

Author:

Dale Carr

Director
Missouri Medicaid Audit and Compliance (MMAC)

Dale Carr currently serves as Director of the Missouri Medicaid Audit & Compliance (MMAC) unit, which
has overall responsibility for Medicaid program integrity efforts. Dale has worked for the State of
Missouri since 2011. Director Carr was previously a Police Officer in Fallon, NV; an Investigator for the
U.S. Office of Special Counsel; and a Supervisory Special Agent with the Coast Guard Investigative
Service. Dale holds a Bachelor’s degree in Administration of Criminal Justice and is a graduate of the

158th Session of the FBI National Academy.

... read more

Dale Carr

Director
Missouri Medicaid Audit and Compliance (MMAC)

Dale Carr currently serves as Director of the Missouri Medicaid Audit & Compliance (MMAC) unit, which
has overall responsibility for Medicaid program integrity efforts. Dale has worked for the State of
Missouri since 2011. Director Carr was previously a Police Officer in Fallon, NV; an Investigator for the
U.S. Office of Special Counsel; and a Supervisory Special Agent with the Coast Guard Investigative
Service. Dale holds a Bachelor’s degree in Administration of Criminal Justice and is a graduate of the

158th Session of the FBI National Academy.

Author:

Drew Satriano

Vice President of Payment Integrity
Highmark Health
... read more

Drew Satriano

Vice President of Payment Integrity
Highmark Health
09:45

HPRI developed a first of it's kind, payment integrity industry survey, in partnership with the payers that are part of the HPRI network. The survey results are aggregated to provide powerful insights from all of the PI experts across the country. The aim of the survey was to evaluate current trends in the payment integrity market, explore the payer perspective of implications related to the complexity of the market, and gain insights from payers on the introduction of disruptive technologies enabling greater analytics for unstructured data, and
opportunities for future savings in the coming year. Join us for a review of the 2024 PI survey results to help drive your PI initiatives.

- Learn about the most prominent PI trends for 2024
- Explore new innovations and their impact on driving 2024 opportunites
- Leverage survey results to asses where your program and organization fall in relation to your peers in the industry

Author:

Dave Cardelle

Chief Strategy Officer
AMS
... read more

Dave Cardelle

Chief Strategy Officer
AMS
10:15
11:00

History of Hospital at Home and Telehealth Services
Post Pandemic Growth and Barriers
Hospital at Home vs Home Health

Reduced Payer and Provider Costs
Developing Reimbursement Policies
Identifying Potential Fraud, Waste and Abuse

Lesson objectives:

- Overall knowledge of hospital at home and telehealth services
- How to create effective reimbursement policies for emerging healthcare services

Author:

Cereasa Horner

Director of Policy and Payment Integrity
CERIS

Cereasa Horner, MHA, is the Director of Policy and Payment Integrity for CERIS, a CorVel company. Cereasa has been an integral part of the CERIS team since 2017, and throughout her tenure, she has consistently displayed a rare combination of leadership, innovation, and a deep understanding of the healthcare industry. Her dedication to the mission and values of CERIS Health has been evident in every aspect of her work. She has developed CERIS’ internal payment integrity program and partnered with health plans to create and implement reimbursement policies related to claim audits. 

... read more

Cereasa Horner

Director of Policy and Payment Integrity
CERIS

Cereasa Horner, MHA, is the Director of Policy and Payment Integrity for CERIS, a CorVel company. Cereasa has been an integral part of the CERIS team since 2017, and throughout her tenure, she has consistently displayed a rare combination of leadership, innovation, and a deep understanding of the healthcare industry. Her dedication to the mission and values of CERIS Health has been evident in every aspect of her work. She has developed CERIS’ internal payment integrity program and partnered with health plans to create and implement reimbursement policies related to claim audits. 

The healthcare landscape is fraught with complexity and financial pitfalls and small-to-medium-sized health plans often find themselves vulnerable to inflated claims, hemorrhaging millions annually.

Payment integrity products like DRG Coding and Clinical Validation, Hospital Bill Audits, Data Mining, and more, can offer immediate reinforcement against dubious claims. But which products should be deployed, when should they be implemented, what are the best practices for their utilization, and how do you effectively evaluate their impact?

In this session, discover how merging clinical expertise with AI technology enhances payment integrity solutions and evaluate in-house, outsourced, or combined approaches based on reassignment and appeal overturn rates for optimal financial protection.

In a world where healthcare fraud runs rampant and financial losses mount, a strategic plan for payment integrity stands as a beacon of hope for small to medium-sized health plans, offering a formidable defense against the forces of fiscal depletion. This discussion will provide a framework for developing a strategic approach to financial stability.

Author:

Ted Pitynski

Chief Commercial Officer
MedReview

As the Chief Commercial Officer, Ted is responsible for the commercial growth of the company through his leadership of sales, marketing, and product management. Ted brings a wealth of knowledge from more than two decades of experience developing go-to-market strategies for selling complex healthcare solutions to payers, government agencies, benefit trusts and employers. Ted collaborates with sales teams, prospects, partners, and customers to capitalize on revenue-enhancing opportunities, setting new standards in the payment integrity industry.

Prior to joining MedReview, Ted transitioned from the finance sector to healthcare with a fervent commitment to revolutionizing the healthcare landscape. He was previously the Vice President of Self-Insured Solutions and Partnerships for ArmadaHealth, where he developed and executed the company’s distribution strategy. Ted also spent eight years as the Director of Health Plan Partnerships for HealthMedia, a wholly owned subsidiary of Johnson & Johnson.

... read more

Ted Pitynski

Chief Commercial Officer
MedReview

As the Chief Commercial Officer, Ted is responsible for the commercial growth of the company through his leadership of sales, marketing, and product management. Ted brings a wealth of knowledge from more than two decades of experience developing go-to-market strategies for selling complex healthcare solutions to payers, government agencies, benefit trusts and employers. Ted collaborates with sales teams, prospects, partners, and customers to capitalize on revenue-enhancing opportunities, setting new standards in the payment integrity industry.

Prior to joining MedReview, Ted transitioned from the finance sector to healthcare with a fervent commitment to revolutionizing the healthcare landscape. He was previously the Vice President of Self-Insured Solutions and Partnerships for ArmadaHealth, where he developed and executed the company’s distribution strategy. Ted also spent eight years as the Director of Health Plan Partnerships for HealthMedia, a wholly owned subsidiary of Johnson & Johnson.

11:30

Learn how one health plan worked to implement both primary care capitation and global capitation in their market.  The healthplan will explain how they leveraged their provider relationships to develop capitation models, configured their systems to pay capitation and were able to deepen the collaboration with providers.

1. Learn how to leverage your system capabilities and data to implement capitation.

2. Explore better strategies to collaborate with providers implementing payment change.

3. Understand how to measure success under a capitated contract.

Track 1: Advanced Payment Integrity Function

Author:

Cathy Newman

Managing Director Value-Based Strategy
Blue Cross Blue Shield of Rhode Island

Cathy Newman is the Managing Director of Value-Based strategy for Blue Cross Blue Shield of Rhode Island.  Her experience in the healthcare industry spans over twenty years working for both large integrated providers, small IPAs, and health plans.  In her ten years with Blue Cross, she has worked to advance value-based opportunities from pay for performance to full-risk global capitation models.  She is passionate about her work and has been able to develop more collaborative and meaningful relationships with providers throughout the state of Rhode Island.

... read more

Cathy Newman

Managing Director Value-Based Strategy
Blue Cross Blue Shield of Rhode Island

Cathy Newman is the Managing Director of Value-Based strategy for Blue Cross Blue Shield of Rhode Island.  Her experience in the healthcare industry spans over twenty years working for both large integrated providers, small IPAs, and health plans.  In her ten years with Blue Cross, she has worked to advance value-based opportunities from pay for performance to full-risk global capitation models.  She is passionate about her work and has been able to develop more collaborative and meaningful relationships with providers throughout the state of Rhode Island.

  1. Gain a comprehensive understanding of payment integrity functions and the initial steps required to establish a payment integrity team.
  2. Learn about vendor setup and staffing strategies essential for building a successful payment integrity function.
  3. Understand the fundamentals of payment integrity 
Track 2: Developing Payment Integrity Function

Author:

Monique Pierce

Head of Payment Integrity
Devoted Health

Monique is a Strategic Executive Healthcare Leader with proven ability to develop solutions and maximize the benefits of Payment Integrity programs.  She is known for having excellent domain knowledge and being driven, high performing, and having a deep dedication to recruiting and developing top talent.

 

Monique started her Payment Integrity career at Oxford HealthPlans in the COB and Subrogation Department after spending time in Payment Policy.  When United Healthcare acquired many health plans in the early 2000s like Oxford, Monique was tagged as part of the Optum team to integrate the processes and people into the COB systems that she had built at Oxford.  She led systems development, quality, reporting, operations, vendor management and was responsible for creating innovative proactive programs that more than doubled savings to $1.4B in three years.

 

Monique developed a successful program that reduced interest expense on late claims for UHC, assisted a communication company to develop COB tools and assisted in strategic system projects before joining SCIO Health Analytics in 2014 to develop new products - specifically prepayment programs.

In 2015 she became the product owner of SCIOMine, the company’s internal audit application and managed the roadmap.  Monique also owned

strategic direction for operational metrics and reporting including executive scorecards. Monique was promoted to VP of Business Opportunities and Client Engagement where she improved Audit Recovery TAT by 39% and reduced client implementations TAT by 11% and the Level of Effort by 18% while increasing the count of implementation projects by 126%.

 

In 2020 Monique joined Devoted Health, a startup company with the goal of building the first ever integrated Payment Integrity Program.  The company has one system, great data, and a great mission; to change health care by treating every member as if they are family.

 

In her spare time, Monique volunteers her time in the community on the Board of Directors of SCARE NH and works in her family business LARP Portal with her husband Rick.

... read more

Monique Pierce

Head of Payment Integrity
Devoted Health

Monique is a Strategic Executive Healthcare Leader with proven ability to develop solutions and maximize the benefits of Payment Integrity programs.  She is known for having excellent domain knowledge and being driven, high performing, and having a deep dedication to recruiting and developing top talent.

 

Monique started her Payment Integrity career at Oxford HealthPlans in the COB and Subrogation Department after spending time in Payment Policy.  When United Healthcare acquired many health plans in the early 2000s like Oxford, Monique was tagged as part of the Optum team to integrate the processes and people into the COB systems that she had built at Oxford.  She led systems development, quality, reporting, operations, vendor management and was responsible for creating innovative proactive programs that more than doubled savings to $1.4B in three years.

 

Monique developed a successful program that reduced interest expense on late claims for UHC, assisted a communication company to develop COB tools and assisted in strategic system projects before joining SCIO Health Analytics in 2014 to develop new products - specifically prepayment programs.

In 2015 she became the product owner of SCIOMine, the company’s internal audit application and managed the roadmap.  Monique also owned

strategic direction for operational metrics and reporting including executive scorecards. Monique was promoted to VP of Business Opportunities and Client Engagement where she improved Audit Recovery TAT by 39% and reduced client implementations TAT by 11% and the Level of Effort by 18% while increasing the count of implementation projects by 126%.

 

In 2020 Monique joined Devoted Health, a startup company with the goal of building the first ever integrated Payment Integrity Program.  The company has one system, great data, and a great mission; to change health care by treating every member as if they are family.

 

In her spare time, Monique volunteers her time in the community on the Board of Directors of SCARE NH and works in her family business LARP Portal with her husband Rick.

Author:

Danielle Nelson

FWA Program Manager
PacificSource Health Plan
... read more

Danielle Nelson

FWA Program Manager
PacificSource Health Plan
12:00

Every payer can agree on one thing. There is fraud, waste, and abuse happening that they cannot see or see fast enough with the limitations of current claims data-centric technology stacks. One more technology in the stack doesn't solve the problem of not being able to see dynamic behaviors, relationships, and outliers that lead to over-payments on basic CMS edits as well as undetected complex fraud and collusion schemes. More claims data-centric technology is not the solution. Dynamic provider-centric risk detection technology coupled with continuously-credentialed provider integrity data is the solution for increased FWA detection and near real-time prevention. That's because stacks of claim data-centric technologies (even those using conventional artificial intelligence) will never see what providers are doing individually, in relationship with all other providers, and in relationship to all other claims on each-and-every claim submitted.

This session will focus on the benefits of a provider-centric FWA prevention approach powered by artificial intelligence that is dynamic and uses both supervised and unsupervised machine learning for detection beyond rules-based technologies. It will highlight strategies for FWA prevention at five points along the claims workflow including pre pre-payment, pre-payment, and post-payment positions. Fraud and SIU teams will be particularly interested in this combination of technologies to detect and automatically package fraud and collusion schemes you can’t see now or can’t see fast enough with the limitations of claim-centric approaches.

1. Understand the FWA detection limitations of claims data-centric approaches
2. Understand how a provider centric-approach such as Integr8 AI increases FWA detection and prevention
3. Understand the benefits of provider-centric FWA prevention pre pre-payment, pre-payment, and post-payment

Author:

Clay Wilemon

Chief Executive Officer
4L Data Intelligence, Inc.

Clay serves as CEO at 4L Data Intelligence™. He has launched over 500 new healthcare brands and holds patents in artificial intelligence and medical technologies. Clay is on the Board of Directors at Octane, a Southern California non-profit economic development organization that has helped hundreds of technology and med-tech companies get started. He a graduate of Vanderbilt University. 

... read more

Clay Wilemon

Chief Executive Officer
4L Data Intelligence, Inc.

Clay serves as CEO at 4L Data Intelligence™. He has launched over 500 new healthcare brands and holds patents in artificial intelligence and medical technologies. Clay is on the Board of Directors at Octane, a Southern California non-profit economic development organization that has helped hundreds of technology and med-tech companies get started. He a graduate of Vanderbilt University. 

Author:

Greg Lyon

Senior Fraud Advisor
4L Data Intelligence, Inc.

Greg is a recognized anti-fraud expert with experience in Financial Services and Healthcare Payments that includes serving as Director of Fraud Prevention at United Healthcare. His guiding principle is, “The best way to fight fraud is to prevent it.” Greg is a graduate of Colgate University and is a Certified Financial Planner.

... read more

Greg Lyon

Senior Fraud Advisor
4L Data Intelligence, Inc.

Greg is a recognized anti-fraud expert with experience in Financial Services and Healthcare Payments that includes serving as Director of Fraud Prevention at United Healthcare. His guiding principle is, “The best way to fight fraud is to prevent it.” Greg is a graduate of Colgate University and is a Certified Financial Planner.

  • This session delves into prevalent billing and coding errors encountered in healthcare reimbursement postpayment and prepayent processes, shedding light on their potential to result in overpayments for payers. Through case studies and practical examples, Healthcare Fraud Shield can showcase effective strategies for identifying common errors, such as incorrect billing of maternity care services.
  • This session will walk through:
      • Appropriate coding for delivery services 
      • Proper billing practices at it relates to antepartum and postpartum care 
      • How to detect patterns of inappropriate claim submissions

Author:

Karen Weintraub

Executive Vice President
HEALTHCARE FRAUD SHIELD

With 25 years of data and 20 years of healthcare experience, Ms. Weintraub is currently responsible for the design and development of the company’s healthcare fraud detection software products and services. She provides subject matter expertise on system design and workflow, business rule development, data mining and fraud outlier algorithms as well as SIU policies and procedures. Prior to joining Healthcare Fraud Shield, managed SIUs on various healthcare investigations for all commercial, Medicaid and Medicare business and claims of fraudulent activity. Ms. Weintraub received a BA in Criminal Justice from the University of Delaware and an MA in Criminal Justice from Rutgers University. Ms. Weintraub is a Certified Professional Coder for Payers (CPC-P), a Certified Professional Medical Auditor (CPMA) from the American Academy of Professional Coders, a Certified Dental Coder (CDC) from the American Dental Association, and the founder of the Hamilton, NJ AAPC chapter. She is also an Accredited Healthcare Fraud Investigator (AHFI) from the National Healthcare Anti-Fraud Association (NHCAA). Ms. Weintraub Taught CPT Coding, Fraud & Audits, and Medical Billing, Laws and Ethics and the local community college. 

... read more

Karen Weintraub

Executive Vice President
HEALTHCARE FRAUD SHIELD

With 25 years of data and 20 years of healthcare experience, Ms. Weintraub is currently responsible for the design and development of the company’s healthcare fraud detection software products and services. She provides subject matter expertise on system design and workflow, business rule development, data mining and fraud outlier algorithms as well as SIU policies and procedures. Prior to joining Healthcare Fraud Shield, managed SIUs on various healthcare investigations for all commercial, Medicaid and Medicare business and claims of fraudulent activity. Ms. Weintraub received a BA in Criminal Justice from the University of Delaware and an MA in Criminal Justice from Rutgers University. Ms. Weintraub is a Certified Professional Coder for Payers (CPC-P), a Certified Professional Medical Auditor (CPMA) from the American Academy of Professional Coders, a Certified Dental Coder (CDC) from the American Dental Association, and the founder of the Hamilton, NJ AAPC chapter. She is also an Accredited Healthcare Fraud Investigator (AHFI) from the National Healthcare Anti-Fraud Association (NHCAA). Ms. Weintraub Taught CPT Coding, Fraud & Audits, and Medical Billing, Laws and Ethics and the local community college. 

12:30
  1. Learn how to develop a patient-centric claims management strategy that prioritizes inclusivity and transparency.
  2. Explore best practices for managing inpatient claims so as to enhance the patient experience.
  3. Understand the importance of inclusive claim management strategies in achieving payment integrity goals.
Track 1: Advanced Payment Integrity Function

Author:

Conor McCauley

Director, Payment Integrity Clinical Capabilites
Highmark Health

My name is Conor McCauley. I am the Director of Payment Integrity Clinical Capabilities at Highmark. Being a Critical Care nurse, it is easy to see there are issues surrounding healthcare funding. Inserting clinical insights into reimbursement methodologies can lead to affordability and improved patient outcomes. Clinicians are well positioned to make a difference here. My passion is developing an engaged team, effective processes, and surrounding clinicians with the right technology, data, and market insights so they can work at the top of their licensure.

... read more

Conor McCauley

Director, Payment Integrity Clinical Capabilites
Highmark Health

My name is Conor McCauley. I am the Director of Payment Integrity Clinical Capabilities at Highmark. Being a Critical Care nurse, it is easy to see there are issues surrounding healthcare funding. Inserting clinical insights into reimbursement methodologies can lead to affordability and improved patient outcomes. Clinicians are well positioned to make a difference here. My passion is developing an engaged team, effective processes, and surrounding clinicians with the right technology, data, and market insights so they can work at the top of their licensure.

Author:

Drew Satriano

Vice President of Payment Integrity
Highmark Health
... read more

Drew Satriano

Vice President of Payment Integrity
Highmark Health
1:00
2:00
  1. Learn strategies for identifying areas of overpayment in healthcare claims processing.
  2. Understand how technology and AI can be leveraged to predict and prevent high-cost overpayments.
  3. Explore best practices for reducing high-cost overpayments, to improve cost containment efforts.
Track 1: Advanced Payment Integrity Function

Author:

Thomas Everett

ex-Sr. Director Operations
Centene Health Plans
... read more

Thomas Everett

ex-Sr. Director Operations
Centene Health Plans
  • This session is designed for organizations without a payment integrity unit presently or a payment integrity unit in its infancy. This presentation will analyze when and how to evaluate pre-pay solutions versus post-pay solutions.
  • The presentation will first explore pre-pay options to enhance with your current claims adjudication system and how to implement a new claims editing system to interface with your current claims adjudication system. For post-pay options, presentation will discuss strategies in terms of first-pass, second-pass, and third-pass solutions. Discussion on post-pay contract negotiations will also be presented along with how to deal with provider and hospital pushback when implementing these new solutions.
  • A brief discussion regarding Coordination of Benefits (COB) will demonstrate that COB is more an enrolment issue versus a claims issue; asking the question: Should COB be considered in a payment integrity unit? The presentation will end with a focus on how to bring all these actions and issues into a new payment integrity unit.
  • Learning Objectives:
    • · Analyze differences between pre-pay and post-pay solutions.
    • · Compare different strategies and vendor solutions for first-pass, second-pass, and third-pass post-pay solutions.
    • · Examine methods to communicate with providers and hospitals to lessen major pushback when implementing these strategies.
    • · Discuss if COB should be a payment integrity issue.
    • · Evaluate different choices for starting a payment integrity unit.

Author:

Dr Michael Seavers

Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics
Harrisburg University

Dr. Michael Seavers is the Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics at Harrisburg University.  Dr. Seavers has a varied background in IT, business, and healthcare spanning many decades.  Dr. Seavers began as a programmer analyst at Shared Medical Systems and later at General Electric in their Aerospace Division.  Dr. Seavers then worked in IT management in the pick-pack-and-ship industry being employed at companies like Book-of-the-Month Club (Time Warner) and Hanover Direct during the .COM expansion.

As the .COM industry went bust, Dr. Seavers moved to the healthcare industry.  Dr. Seavers worked at Capital BlueCross for nearly two decades.  The first decade was as a Senior Manager in the IT department and the second decade as the Senior Director of Claims and later the Senior Director of Enrollment and Billing.  Dr. Seavers focus was automation of labor utilizing software robotics for healthcare. 

After a varied career background and various formal degrees, Dr. Seavers is very pleased to be teaching at Harrisburg University.

... read more

Dr Michael Seavers

Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics
Harrisburg University

Dr. Michael Seavers is the Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics at Harrisburg University.  Dr. Seavers has a varied background in IT, business, and healthcare spanning many decades.  Dr. Seavers began as a programmer analyst at Shared Medical Systems and later at General Electric in their Aerospace Division.  Dr. Seavers then worked in IT management in the pick-pack-and-ship industry being employed at companies like Book-of-the-Month Club (Time Warner) and Hanover Direct during the .COM expansion.

As the .COM industry went bust, Dr. Seavers moved to the healthcare industry.  Dr. Seavers worked at Capital BlueCross for nearly two decades.  The first decade was as a Senior Manager in the IT department and the second decade as the Senior Director of Claims and later the Senior Director of Enrollment and Billing.  Dr. Seavers focus was automation of labor utilizing software robotics for healthcare. 

After a varied career background and various formal degrees, Dr. Seavers is very pleased to be teaching at Harrisburg University.

2:30

Struggling to make sense of large data sets? Join us to learn more about leveraging data analytics to predict savings, prioritize reviews, identify trends and patterns, maximize staffing, and more!

- Understand different types of data analytics applicable to payment integrity
- Best practices to integrate data analytics in your payment integrity program management
- Leveraging data analytics to maximize effectiveness and efficiency

Author:

Karen Ballard

Director of Consulting Services
CGI

Karen Ballard is Director of Consulting Services, CGI, where she is responsible for managing the CGI ProperPay payment integrity platform. With a nearly 20-year career in the health payer space, Karen possesses a deep knowledge of claims processing, product management, payment integrity, and the Blue payer dynamic. Prior to joining CGI, Karen held a variety of positions in claims operations, BlueCard, and payment integrity during her 17-year tenure with Elevance Health (Anthem).

Karen holds a Bachelor of Arts and a Master of Business Administration from Southern New Hampshire University. She co-founded and previously co-facilitated the Blue PI Committee, comprised of payment integrity leaders from all 33 Blue Cross and Blue Shield plans and partnered with the Blue Cross and Blue Shield Association to drive change in the payment integrity space.

... read more

Karen Ballard

Director of Consulting Services
CGI

Karen Ballard is Director of Consulting Services, CGI, where she is responsible for managing the CGI ProperPay payment integrity platform. With a nearly 20-year career in the health payer space, Karen possesses a deep knowledge of claims processing, product management, payment integrity, and the Blue payer dynamic. Prior to joining CGI, Karen held a variety of positions in claims operations, BlueCard, and payment integrity during her 17-year tenure with Elevance Health (Anthem).

Karen holds a Bachelor of Arts and a Master of Business Administration from Southern New Hampshire University. She co-founded and previously co-facilitated the Blue PI Committee, comprised of payment integrity leaders from all 33 Blue Cross and Blue Shield plans and partnered with the Blue Cross and Blue Shield Association to drive change in the payment integrity space.

Author:

David Ott

Director Consulting Payment Integrity
CGI

David Ott has over 28 years of experience in the healthcare and financial services industries. David has provided leadership and direction to department leaders and teams that support a variety of functions, including business development, payment integrity, claims processing, global project management and quality practices.

... read more

David Ott

Director Consulting Payment Integrity
CGI

David Ott has over 28 years of experience in the healthcare and financial services industries. David has provided leadership and direction to department leaders and teams that support a variety of functions, including business development, payment integrity, claims processing, global project management and quality practices.

Health Plans and Hospitals are looking to leverage Price Transparency Data to improve contracting, drive business intelligence and build Payment Integrity use cases.  This session lays out a 2024 road map choosing the right data set and the right partner while also exploring specific use cases for your plan or hospital.

*Understand 5 Key Questions you should be asking any Price Transparency vendor
*Identify specific use cases for Price Transparency Data that will be valuable to your organization

Author:

John-Michael Loke

SVP, Health Plan Strategy & Partnerships
AMS
... read more

John-Michael Loke

SVP, Health Plan Strategy & Partnerships
AMS
3:00
4:00pm
4:30pm

Healthcare payors and providers, as well as employers, are recognizing the importance of value-based care. Pressure to reduce avoidable cost and utilization, coupled with the demand to improve quality outcomes has caused payment models to move from fee-for-service to fee-for value. To succeed in this new paradigm, payors must collaborate with other stakeholders to design and implement value-based care models that meaningful and sustainable. These models must address the needs of all stakeholders, including the payors, providers, employers and the patients.

Learning Objectives:

  • Synergistic opportunities for payors and providers to establish value-based programs
  • Efficient allocation of resources when implementing value-based care
  • Mitigating risk of downside value-based payment models
  • Responding to disruptors

Author:

Frank Shipp

Executive Director
Johns Hopkins CIA
... read more

Frank Shipp

Executive Director
Johns Hopkins CIA
5:15pm
Thursday, 23 May, 2024
09:30

9: 30 – 11 – AI Symposium

9:30 – Introduction

9:30 – 10:30 – The Future of AI in Healthcare Payments (Panel)

Panellists: Monique Pierce, Conor McCauley, Frank Shipp, Tom Everett

Moderator: David Ott, CGI

10:30 – 10:50 – Vendor Demos of AI Capabilities

10:50 – 11:00 – Optimizing AI in Healthcare Payment Integrity

Speaker: Natalie Clayton, Private Consultant

Author:

Monique Pierce

Head of Payment Integrity
Devoted Health

Monique is a Strategic Executive Healthcare Leader with proven ability to develop solutions and maximize the benefits of Payment Integrity programs.  She is known for having excellent domain knowledge and being driven, high performing, and having a deep dedication to recruiting and developing top talent.

 

Monique started her Payment Integrity career at Oxford HealthPlans in the COB and Subrogation Department after spending time in Payment Policy.  When United Healthcare acquired many health plans in the early 2000s like Oxford, Monique was tagged as part of the Optum team to integrate the processes and people into the COB systems that she had built at Oxford.  She led systems development, quality, reporting, operations, vendor management and was responsible for creating innovative proactive programs that more than doubled savings to $1.4B in three years.

 

Monique developed a successful program that reduced interest expense on late claims for UHC, assisted a communication company to develop COB tools and assisted in strategic system projects before joining SCIO Health Analytics in 2014 to develop new products - specifically prepayment programs.

In 2015 she became the product owner of SCIOMine, the company’s internal audit application and managed the roadmap.  Monique also owned

strategic direction for operational metrics and reporting including executive scorecards. Monique was promoted to VP of Business Opportunities and Client Engagement where she improved Audit Recovery TAT by 39% and reduced client implementations TAT by 11% and the Level of Effort by 18% while increasing the count of implementation projects by 126%.

 

In 2020 Monique joined Devoted Health, a startup company with the goal of building the first ever integrated Payment Integrity Program.  The company has one system, great data, and a great mission; to change health care by treating every member as if they are family.

 

In her spare time, Monique volunteers her time in the community on the Board of Directors of SCARE NH and works in her family business LARP Portal with her husband Rick.

... read more

Monique Pierce

Head of Payment Integrity
Devoted Health

Monique is a Strategic Executive Healthcare Leader with proven ability to develop solutions and maximize the benefits of Payment Integrity programs.  She is known for having excellent domain knowledge and being driven, high performing, and having a deep dedication to recruiting and developing top talent.

 

Monique started her Payment Integrity career at Oxford HealthPlans in the COB and Subrogation Department after spending time in Payment Policy.  When United Healthcare acquired many health plans in the early 2000s like Oxford, Monique was tagged as part of the Optum team to integrate the processes and people into the COB systems that she had built at Oxford.  She led systems development, quality, reporting, operations, vendor management and was responsible for creating innovative proactive programs that more than doubled savings to $1.4B in three years.

 

Monique developed a successful program that reduced interest expense on late claims for UHC, assisted a communication company to develop COB tools and assisted in strategic system projects before joining SCIO Health Analytics in 2014 to develop new products - specifically prepayment programs.

In 2015 she became the product owner of SCIOMine, the company’s internal audit application and managed the roadmap.  Monique also owned

strategic direction for operational metrics and reporting including executive scorecards. Monique was promoted to VP of Business Opportunities and Client Engagement where she improved Audit Recovery TAT by 39% and reduced client implementations TAT by 11% and the Level of Effort by 18% while increasing the count of implementation projects by 126%.

 

In 2020 Monique joined Devoted Health, a startup company with the goal of building the first ever integrated Payment Integrity Program.  The company has one system, great data, and a great mission; to change health care by treating every member as if they are family.

 

In her spare time, Monique volunteers her time in the community on the Board of Directors of SCARE NH and works in her family business LARP Portal with her husband Rick.

Author:

Conor McCauley

Director, Payment Integrity Clinical Capabilites
Highmark Health

My name is Conor McCauley. I am the Director of Payment Integrity Clinical Capabilities at Highmark. Being a Critical Care nurse, it is easy to see there are issues surrounding healthcare funding. Inserting clinical insights into reimbursement methodologies can lead to affordability and improved patient outcomes. Clinicians are well positioned to make a difference here. My passion is developing an engaged team, effective processes, and surrounding clinicians with the right technology, data, and market insights so they can work at the top of their licensure.

... read more

Conor McCauley

Director, Payment Integrity Clinical Capabilites
Highmark Health

My name is Conor McCauley. I am the Director of Payment Integrity Clinical Capabilities at Highmark. Being a Critical Care nurse, it is easy to see there are issues surrounding healthcare funding. Inserting clinical insights into reimbursement methodologies can lead to affordability and improved patient outcomes. Clinicians are well positioned to make a difference here. My passion is developing an engaged team, effective processes, and surrounding clinicians with the right technology, data, and market insights so they can work at the top of their licensure.

Author:

Frank Shipp

Executive Director
Johns Hopkins CIA
... read more

Frank Shipp

Executive Director
Johns Hopkins CIA

Author:

Thomas Everett

ex-Sr. Director Operations
Centene Health Plans
... read more

Thomas Everett

ex-Sr. Director Operations
Centene Health Plans

Author:

David Ott

Director Consulting Payment Integrity
CGI

David Ott has over 28 years of experience in the healthcare and financial services industries. David has provided leadership and direction to department leaders and teams that support a variety of functions, including business development, payment integrity, claims processing, global project management and quality practices.

... read more

David Ott

Director Consulting Payment Integrity
CGI

David Ott has over 28 years of experience in the healthcare and financial services industries. David has provided leadership and direction to department leaders and teams that support a variety of functions, including business development, payment integrity, claims processing, global project management and quality practices.

11:00
11:30
  1. Discover strategies to enhance collaboration between hospitals and health plans with a focus on financial responsibility divisions and the impact of emerging technologies on reinsurance.
  2. Prioritize patient-centered collaboration to improve outcomes and reduce readmissions.
  3. Learn to modernize appeal processes and strengthen payer-provider relationships through improved communication and clearly established contract terms and individual preferences. 

Author:

Dr Michael Seavers

Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics
Harrisburg University

Dr. Michael Seavers is the Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics at Harrisburg University.  Dr. Seavers has a varied background in IT, business, and healthcare spanning many decades.  Dr. Seavers began as a programmer analyst at Shared Medical Systems and later at General Electric in their Aerospace Division.  Dr. Seavers then worked in IT management in the pick-pack-and-ship industry being employed at companies like Book-of-the-Month Club (Time Warner) and Hanover Direct during the .COM expansion.

As the .COM industry went bust, Dr. Seavers moved to the healthcare industry.  Dr. Seavers worked at Capital BlueCross for nearly two decades.  The first decade was as a Senior Manager in the IT department and the second decade as the Senior Director of Claims and later the Senior Director of Enrollment and Billing.  Dr. Seavers focus was automation of labor utilizing software robotics for healthcare. 

After a varied career background and various formal degrees, Dr. Seavers is very pleased to be teaching at Harrisburg University.

... read more

Dr Michael Seavers

Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics
Harrisburg University

Dr. Michael Seavers is the Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics at Harrisburg University.  Dr. Seavers has a varied background in IT, business, and healthcare spanning many decades.  Dr. Seavers began as a programmer analyst at Shared Medical Systems and later at General Electric in their Aerospace Division.  Dr. Seavers then worked in IT management in the pick-pack-and-ship industry being employed at companies like Book-of-the-Month Club (Time Warner) and Hanover Direct during the .COM expansion.

As the .COM industry went bust, Dr. Seavers moved to the healthcare industry.  Dr. Seavers worked at Capital BlueCross for nearly two decades.  The first decade was as a Senior Manager in the IT department and the second decade as the Senior Director of Claims and later the Senior Director of Enrollment and Billing.  Dr. Seavers focus was automation of labor utilizing software robotics for healthcare. 

After a varied career background and various formal degrees, Dr. Seavers is very pleased to be teaching at Harrisburg University.

Author:

Melissa Hinckley

VP of Network Strategy and Operations
Point32Health
... read more

Melissa Hinckley

VP of Network Strategy and Operations
Point32Health

Author:

Corella Lumpkins

Manager of Coding, Compliance and Provider Education
Loudoun Medical Group P.C.
... read more

Corella Lumpkins

Manager of Coding, Compliance and Provider Education
Loudoun Medical Group P.C.

Author:

Dave Cardelle

Chief Strategy Officer
AMS
... read more

Dave Cardelle

Chief Strategy Officer
AMS

Author:

Vladimir-Ducarmel Joseph

CDI Program Manager
Beth Israel Lahey Health Hospital & Medical Center

Vladimir-Ducarmel Joseph is one of the Clinical Documentation Integrity Program Directors at Beth Israel Lahey Health, where he spearheads a dedicated team of CDI professional experts to optimize clinical documentation best practices. With almost a decade in CDI leadership across diverse healthcare environments, Vladimir-Ducarmel holds a Master of Health Administration from George Washington University and his expertise encompasses physician leadership, team dynamics, CDI provider education, and program management. A fervent advocate for healthcare excellence, Vladimir-Ducarmel is adept at bridging the gap between clinical and administrative roles. He is proficient in various healthcare-oriented analytical and business tools, leveraging them to drive impactful CDI outcomes.

... read more

Vladimir-Ducarmel Joseph

CDI Program Manager
Beth Israel Lahey Health Hospital & Medical Center

Vladimir-Ducarmel Joseph is one of the Clinical Documentation Integrity Program Directors at Beth Israel Lahey Health, where he spearheads a dedicated team of CDI professional experts to optimize clinical documentation best practices. With almost a decade in CDI leadership across diverse healthcare environments, Vladimir-Ducarmel holds a Master of Health Administration from George Washington University and his expertise encompasses physician leadership, team dynamics, CDI provider education, and program management. A fervent advocate for healthcare excellence, Vladimir-Ducarmel is adept at bridging the gap between clinical and administrative roles. He is proficient in various healthcare-oriented analytical and business tools, leveraging them to drive impactful CDI outcomes.

12:15
1:15
    • Update on new CPT codes and "old" CPT codes and how to document
    • Learning Objectives:
      • Learn about new CPT codes coming January 2025
      • Understand the documentation required for the codes

Author:

David Flannery

Director of Telegenetics and Digital Genetics
Cleveland Clinic

David Flannery is a "pioneer" in telemedicine, having started telegenetics clinic in 1995 in Georgia. He’s currently the Director of Telegenetics and Digital Genetics at Cleveland Clinic. He has expertise with ICD-10 coding and CPT codes. He oversaw the revenue cycle management for the 300+ physician practice group at the Medical College of Georgia. He served on the American Medical Association's Digital Medicine Payment Advisory Group, developing new CPT codes for telemedicine and digital medicine.

... read more

David Flannery

Director of Telegenetics and Digital Genetics
Cleveland Clinic

David Flannery is a "pioneer" in telemedicine, having started telegenetics clinic in 1995 in Georgia. He’s currently the Director of Telegenetics and Digital Genetics at Cleveland Clinic. He has expertise with ICD-10 coding and CPT codes. He oversaw the revenue cycle management for the 300+ physician practice group at the Medical College of Georgia. He served on the American Medical Association's Digital Medicine Payment Advisory Group, developing new CPT codes for telemedicine and digital medicine.

1:45
  1. Understand the role of payers, providers, CMS, and PBMs in effectively combatting pharmacy fraud.
  2. Learn strategies for identifying fraudulent prescriptions and reducing waste through collaborative efforts.
  3. Explore ways to establish effective communication networks between these groups to prevent duplicate claims.

Author:

Michael Devine

Director Special Investigations Unit
L.A Care
... read more

Michael Devine

Director Special Investigations Unit
L.A Care
2:15

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