HPRI South Agenda | Kisaco Research

HPRI South Agenda

3rd Annual Healthcare Payment & Revenue Integrity Congress South | February 2025
February 2025
Miami
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Printable version

Wednesday, 7 Feb, 2024
9:00am

Author:

Novelette Wallace, MPH, PMP, CSSBB

Head of Payment Integrity
Johns Hopkins Healthcare

Novelette Wallace is a distinguished Payment Integrity Leader with a rich background spanning over 30 years in the healthcare industry. Her extensive experience includes leadership roles within payment integrity, where she has played pivotal roles in both payment integrity vendor organizations and health plans. Throughout her career, Novelette has demonstrated a remarkable ability to build and lead Payment Integrity departments from their inception. Her expertise has been instrumental in establishing robust processes and strategies to identify and recover inaccuracies in claims, contributing significantly to cost of care savings for health plans year after year.

Novelette has held key leadership positions with industry-leading organizations, including Performant Corp, United Healthcare, and Aetna (previously Coventry). In each role, she has consistently delivered results by optimizing payment integrity processes and driving operational excellence. Currently serving as the Assistant Vice President (AVP) of Payment Integrity for Johns Hopkins Health Plans, Novelette continues to bring her wealth of knowledge and leadership acumen to the forefront. Her dedication to achieving and surpassing cost of care savings goals exemplifies her commitment to advancing the financial health and efficiency of healthcare organizations.

With a proven track record of success and a comprehensive understanding of payment integrity within the healthcare landscape, Novelette Wallace stands as a respected leader in the industry, contributing significantly to the success of the organizations she serve

... read more

Novelette Wallace, MPH, PMP, CSSBB

Head of Payment Integrity
Johns Hopkins Healthcare

Novelette Wallace is a distinguished Payment Integrity Leader with a rich background spanning over 30 years in the healthcare industry. Her extensive experience includes leadership roles within payment integrity, where she has played pivotal roles in both payment integrity vendor organizations and health plans. Throughout her career, Novelette has demonstrated a remarkable ability to build and lead Payment Integrity departments from their inception. Her expertise has been instrumental in establishing robust processes and strategies to identify and recover inaccuracies in claims, contributing significantly to cost of care savings for health plans year after year.

Novelette has held key leadership positions with industry-leading organizations, including Performant Corp, United Healthcare, and Aetna (previously Coventry). In each role, she has consistently delivered results by optimizing payment integrity processes and driving operational excellence. Currently serving as the Assistant Vice President (AVP) of Payment Integrity for Johns Hopkins Health Plans, Novelette continues to bring her wealth of knowledge and leadership acumen to the forefront. Her dedication to achieving and surpassing cost of care savings goals exemplifies her commitment to advancing the financial health and efficiency of healthcare organizations.

With a proven track record of success and a comprehensive understanding of payment integrity within the healthcare landscape, Novelette Wallace stands as a respected leader in the industry, contributing significantly to the success of the organizations she serve

9:30am

2024 is critical for Health Plan Payment Integrity Leadership.  With new and legacy pressures being placed on Internal PI Teams what are the opportunities and challenges in 2024 and beyond.  Explore how to leverage your internal resources, leading edge technologies, and HPRI relationships to drive success in the coming year.  

Author:

John-Michael Loke

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

John-Michael Loke

SVP, Health Plan Strategy & Partnerships
AMS
10:00am
10:30am

Author:

Harold Davis

VP, Product Growth
Rialtic
... read more

Harold Davis

VP, Product Growth
Rialtic
11:00am
11:30am
Track 1

Author:

Lacey Crowl

VP of Health Plan Operations
Longevity Health Plan

Lacey Crowl is the Director of Claims Operations for Longevity Health Plan, responsible for the accuracy of claims processing focused on Medicare members. Lacey has experience in the Commercial, Medicare and Medicaid environments, developing prospective and retrospective payment integrity solutions for both clinical and claim coding reviews. She has operated within various claims processing platforms to develop, code and implement new audit concepts while operating within the Managed Care space.

... read more

Lacey Crowl

VP of Health Plan Operations
Longevity Health Plan

Lacey Crowl is the Director of Claims Operations for Longevity Health Plan, responsible for the accuracy of claims processing focused on Medicare members. Lacey has experience in the Commercial, Medicare and Medicaid environments, developing prospective and retrospective payment integrity solutions for both clinical and claim coding reviews. She has operated within various claims processing platforms to develop, code and implement new audit concepts while operating within the Managed Care space.

During this presentation, Dr Archer and Dr Goyal will:

  • Share the idea of clinically integrated revenue cycle key components
  • Examine the roles of the clinicians and the revenue cycle staff at each step in the revenue cycle
  • Analyze the effects of the clinically integrated revenue cycle in change management in its impact on clinical outcomes, experience and cost of care.
Track 2

Author:

Dr Deepak Goyal, MD, MBBS, MBA, CPE, CHCQM, CMRP, CMPC

Executive Medical Director Revenue Cycle and Supply Chain
Monument Health
... read more

Dr Deepak Goyal, MD, MBBS, MBA, CPE, CHCQM, CMRP, CMPC

Executive Medical Director Revenue Cycle and Supply Chain
Monument Health

Author:

Dr Brad Archer

Chief Medical Officer
Monument Health
... read more

Dr Brad Archer

Chief Medical Officer
Monument Health
12:00pm

This session will walk through examples of using expert analytics to detect and prevent improper payments.  In addition to analytics, time saving efficiencies and automation are integral to maximizing value and productivity.  We will discuss how automated intelligent analysis in combination with workflows designed by subject matter experts will drive actionable insights and increased savings. 

Track 1

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. 

David Flannery will talk about coding and documentation for telemedicine, payers' coverage policy (including private payers and Medicare) and regulatory aspects, including credentialling, licensing, and payment parity.

Track 2

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.

12:30pm

Baize will speak about new federal payment integrity efforts that affect Medicare and Medicaid. These efforts will focus on fee-for-service payments, Medicare Advantage, and Medicaid managed care.  As the line between public payers and private payers continues to be blurred, the policies and rules coming out of the federal Centers for Medicare and Medicaid Services (CMS) will affect nearly every payer and plan.

CMS continues to place much of its focus on healthcare supplies and services that are fulfilled outside institutional settings.  Home-based care, durable medical equipment and disposable medical supplies remain under increased scrutiny as areas that CMS has deemed at high risk for fraud.  Laboratories and specialty pharmacies are also being more closely monitored.

Additionally, as required by the 21st CURES Act, electronic visit verification (EVV) of home-based services is now implemented throughout the U.S. Payers should see a reduction in claims for those services, but that depends on whether states implemented EVV consistently, and whether providers willing to commit fraud have already found ways around the technology.

Finally, Baize will provide recent examples of successful healthcare fraud prosecutions from around the U.S.

Track 1

Author:

Anthony Baize

Inspector General
Wisconsin Department of Health Services

Anthony Baize has been the Inspector General for the Wisconsin Department of Health Services since 2016.  He holds a master's degree in public administration from Indiana State University and a Certified Inspector General (CIG) credential from the Association of Inspectors General.  Prior to joining Wisconsin state government, Baize was the deputy director of audits and investigations for the Office of the Inspector General for the Kentucky Cabinet of Health and Family Services.

... read more

Anthony Baize

Inspector General
Wisconsin Department of Health Services

Anthony Baize has been the Inspector General for the Wisconsin Department of Health Services since 2016.  He holds a master's degree in public administration from Indiana State University and a Certified Inspector General (CIG) credential from the Association of Inspectors General.  Prior to joining Wisconsin state government, Baize was the deputy director of audits and investigations for the Office of the Inspector General for the Kentucky Cabinet of Health and Family Services.

The session uses a case study to demonstrate the value of tracking audit, appeal, and overturn success rates. Lessons learned from audit response methods will be reviewed to highlight successful strategies in the early stages of the review process. Actionable and practical steps will be incorporated to illustrate how various stages of the audit and appeal process can be managed.

Track 2

Author:

Richelle Marting, JD, MHSA,RHIA,CPC,CEMC,CPMA

Director of Managed Care
North Kansas City Hospital
... read more

Richelle Marting, JD, MHSA,RHIA,CPC,CEMC,CPMA

Director of Managed Care
North Kansas City Hospital
1:00pm
1:30pm
2:30pm

Vendor management strategies for payment integrity are essential to ensure that your organization optimizes financial processes and ensures the recovery of overpayment.  Here are some strategies that we will discuss:

  • Vendor Selection and Due Diligence
  • Stacking Vendors and multi-vendor approach
  • Vendor Performance Metrics
  • Data Sharing Protocols
  • Payment integrity program options
Track 1

Author:

Novelette Wallace, MPH, PMP, CSSBB

Head of Payment Integrity
Johns Hopkins Healthcare

Novelette Wallace is a distinguished Payment Integrity Leader with a rich background spanning over 30 years in the healthcare industry. Her extensive experience includes leadership roles within payment integrity, where she has played pivotal roles in both payment integrity vendor organizations and health plans. Throughout her career, Novelette has demonstrated a remarkable ability to build and lead Payment Integrity departments from their inception. Her expertise has been instrumental in establishing robust processes and strategies to identify and recover inaccuracies in claims, contributing significantly to cost of care savings for health plans year after year.

Novelette has held key leadership positions with industry-leading organizations, including Performant Corp, United Healthcare, and Aetna (previously Coventry). In each role, she has consistently delivered results by optimizing payment integrity processes and driving operational excellence. Currently serving as the Assistant Vice President (AVP) of Payment Integrity for Johns Hopkins Health Plans, Novelette continues to bring her wealth of knowledge and leadership acumen to the forefront. Her dedication to achieving and surpassing cost of care savings goals exemplifies her commitment to advancing the financial health and efficiency of healthcare organizations.

With a proven track record of success and a comprehensive understanding of payment integrity within the healthcare landscape, Novelette Wallace stands as a respected leader in the industry, contributing significantly to the success of the organizations she serve

... read more

Novelette Wallace, MPH, PMP, CSSBB

Head of Payment Integrity
Johns Hopkins Healthcare

Novelette Wallace is a distinguished Payment Integrity Leader with a rich background spanning over 30 years in the healthcare industry. Her extensive experience includes leadership roles within payment integrity, where she has played pivotal roles in both payment integrity vendor organizations and health plans. Throughout her career, Novelette has demonstrated a remarkable ability to build and lead Payment Integrity departments from their inception. Her expertise has been instrumental in establishing robust processes and strategies to identify and recover inaccuracies in claims, contributing significantly to cost of care savings for health plans year after year.

Novelette has held key leadership positions with industry-leading organizations, including Performant Corp, United Healthcare, and Aetna (previously Coventry). In each role, she has consistently delivered results by optimizing payment integrity processes and driving operational excellence. Currently serving as the Assistant Vice President (AVP) of Payment Integrity for Johns Hopkins Health Plans, Novelette continues to bring her wealth of knowledge and leadership acumen to the forefront. Her dedication to achieving and surpassing cost of care savings goals exemplifies her commitment to advancing the financial health and efficiency of healthcare organizations.

With a proven track record of success and a comprehensive understanding of payment integrity within the healthcare landscape, Novelette Wallace stands as a respected leader in the industry, contributing significantly to the success of the organizations she serve

3:00pm

Achieving a robust and balanced healthcare ecosystem entails embracing moderation, even in the realm of “provider abrasion”. This discourse delves into the nuanced understanding that certain elements perceived as abrasive by healthcare providers may, in fact, be essential. The exploration extends to strategies aimed at rendering these interactions more palatable. Additionally, an examination of measures payors can employ to mitigate provider abrasion, without undermining their payment integrity processes, will be explored.

Track 1

Author:

Dr. Michael Menen

Chief Medical Officer
MedReview
•Former Chief Medical Officer at Optum
•Bachelor of Science degree in theoretical mathematics from the University of California, Riverside
•Doctor of Medicine degree from the Medical College of Wisconsin
•Board-certified invasive cardiologist and a fellow of the American College of Cardiology
... read more

Dr. Michael Menen

Chief Medical Officer
MedReview
•Former Chief Medical Officer at Optum
•Bachelor of Science degree in theoretical mathematics from the University of California, Riverside
•Doctor of Medicine degree from the Medical College of Wisconsin
•Board-certified invasive cardiologist and a fellow of the American College of Cardiology
Track 2
Moderator

Author:

Kyle Pankey

Sales & Growth Leader
Carelon Subrogation

Kyle Pankey has over two decades of experience working within the healthcare and payer operations, with over 10 years specifically tied in to the payment integrity space.   Kyle lives in Chattanooga, TN and has served as Carelon Subrogation’s growth leader since mid-2022.

... read more

Kyle Pankey

Sales & Growth Leader
Carelon Subrogation

Kyle Pankey has over two decades of experience working within the healthcare and payer operations, with over 10 years specifically tied in to the payment integrity space.   Kyle lives in Chattanooga, TN and has served as Carelon Subrogation’s growth leader since mid-2022.

Panelists

Author:

Aaron Browder

President
Carelon Subrogation

Aaron Browder is Staff Vice President, Elevance Health and President, Carelon Subrogation, formerly Meridian Resource Company (Meridian), where he and his team are responsible for overseeing the successful implementation and execution of our clients’ end-to-end subrogation programs. With a nearly 20-year career in subrogation, Aaron possesses a deep knowledge of healthcare subrogation. He has held a wide range of management positions throughout his tenure at Meridian, most recently serving as Staff Vice President. Prior to joining Meridian, Aaron gained experience in the financial services and insurance industries with Arthur Andersen, LLP/KPMG, LLP, and Travelers Property Casualty.

Aaron holds a Bachelor of Arts degree from Indiana University and a Master of Business Administration from Butler University. He served on the Board of Directors for the National Association of Subrogation Professionals and has been a national presenter and author on issues related to subrogation.

 

... read more

Aaron Browder

President
Carelon Subrogation

Aaron Browder is Staff Vice President, Elevance Health and President, Carelon Subrogation, formerly Meridian Resource Company (Meridian), where he and his team are responsible for overseeing the successful implementation and execution of our clients’ end-to-end subrogation programs. With a nearly 20-year career in subrogation, Aaron possesses a deep knowledge of healthcare subrogation. He has held a wide range of management positions throughout his tenure at Meridian, most recently serving as Staff Vice President. Prior to joining Meridian, Aaron gained experience in the financial services and insurance industries with Arthur Andersen, LLP/KPMG, LLP, and Travelers Property Casualty.

Aaron holds a Bachelor of Arts degree from Indiana University and a Master of Business Administration from Butler University. He served on the Board of Directors for the National Association of Subrogation Professionals and has been a national presenter and author on issues related to subrogation.

 

Author:

Sherri Richardson

Strategy, Growth and Program Director
Carelon

As a strategic leader in Program Integrity Health Insurer industry and having mastered the world of “coordination of benefits”, Sherri is passionate about helping our customers and peers navigate the complex world of healthcare. With a proven track record of success in optimizing program efficiency and minimizing cost of care for Members who are eligible/entitled to two health coverages, Sherri is dedicated to ensuring the industry processes are focused on minimizing members out of pocket and provider/insurers administrative costs.

Sherri has 30+ years Health Insurer Industry experience. Operational Excellence, mapping program Strategy is Her Leadership background includes leading highly productive operational teams and all functions of COB Operations within the Commercial, Medicare, Affordable Care Act, Medicaid, Subrogation and Senior market.

As an Elevance/Carelon Corporate Presenter, Sherri enjoys developing training and motivational material, as well as sharing her knowledge and best practices related to maximizing Health Coverage with members, groups, providers and other insurer peers.

Sherri’s experience in health insurance runs deeps, having the privilege of leadership at Elevance/Carelon for 30+ years, and mentoring from industry leaders. Sherri is a life-long learner and strongly encourages others to learn and grow through continued experiences and educational opportunities.

On a personal note; As a prior Fitness Trainer, Sherri enjoys Weight Training, Yoga, Aerial Silks, and Master Swimming.  Oftentimes joins the local 5K runs and loves to cook.   

... read more

Sherri Richardson

Strategy, Growth and Program Director
Carelon

As a strategic leader in Program Integrity Health Insurer industry and having mastered the world of “coordination of benefits”, Sherri is passionate about helping our customers and peers navigate the complex world of healthcare. With a proven track record of success in optimizing program efficiency and minimizing cost of care for Members who are eligible/entitled to two health coverages, Sherri is dedicated to ensuring the industry processes are focused on minimizing members out of pocket and provider/insurers administrative costs.

Sherri has 30+ years Health Insurer Industry experience. Operational Excellence, mapping program Strategy is Her Leadership background includes leading highly productive operational teams and all functions of COB Operations within the Commercial, Medicare, Affordable Care Act, Medicaid, Subrogation and Senior market.

As an Elevance/Carelon Corporate Presenter, Sherri enjoys developing training and motivational material, as well as sharing her knowledge and best practices related to maximizing Health Coverage with members, groups, providers and other insurer peers.

Sherri’s experience in health insurance runs deeps, having the privilege of leadership at Elevance/Carelon for 30+ years, and mentoring from industry leaders. Sherri is a life-long learner and strongly encourages others to learn and grow through continued experiences and educational opportunities.

On a personal note; As a prior Fitness Trainer, Sherri enjoys Weight Training, Yoga, Aerial Silks, and Master Swimming.  Oftentimes joins the local 5K runs and loves to cook.   

Author:

Alan Coulter

VP of Business Development
Performant
... read more

Alan Coulter

VP of Business Development
Performant
3:30pm
4:00pm

Author:

Toni Case

Vice President, National Sales
CERIS
... read more

Toni Case

Vice President, National Sales
CERIS

Author:

Debra Hamer

Director, FWA Analytics
CERIS
... read more

Debra Hamer

Director, FWA Analytics
CERIS
4:30pm
Moderator

Author:

David V. Cardelle, R.Ph.

Chief Strategy Officer, SVP, Health Plan Strategy & Partnerships
Advanced Medical Strategies
... read more

David V. Cardelle, R.Ph.

Chief Strategy Officer, SVP, Health Plan Strategy & Partnerships
Advanced Medical Strategies
Panelists

Author:

Dr. Ahmad Kilani MD, MBA, MLS, MSIT, CHCQM-PHYADV, FACP, FACHE

Medical Director
Cleveland Clinic
... read more

Dr. Ahmad Kilani MD, MBA, MLS, MSIT, CHCQM-PHYADV, FACP, FACHE

Medical Director
Cleveland Clinic

Author:

Kelly Springmann

Provider Enablement & Product Development
Florida Blue
... read more

Kelly Springmann

Provider Enablement & Product Development
Florida Blue

Author:

Jenny Raulerson, BSN, MSHI

Sr Clinical Consultant
Florida Blue
... read more

Jenny Raulerson, BSN, MSHI

Sr Clinical Consultant
Florida Blue
5:15pm
6:15pm
Thursday, 8 Feb, 2024
9:00am

While surgical implants are designed to be discreet and invisible for patients, for payers, implant costs can have a very noticeable impact on spending. Many health plans overpay for surgical implants due to lack of true cost transparency, national price variations, and incorrect billing for non-implantable items. The amount paid by health plans is often significantly higher than the provider’s true acquisition cost, equating to markups of 1,000% or more at times.

While off-the-shelf bill review solutions identify some savings, not all solutions are created equal. Comprehensive programs where the bill review process is managed end-to-end by industry experts and that are backed by the most up-to-date facility-specific implant cost data have been independently validated to deliver consistently greater savings.

Join this roundtable discussion to learn best practices for managing your surgical implant costs. We will cover what to look for when selecting a payment integrity partner to generate maximum cost savings, how to ensure durable and defensible savings that hold up through reconsiderations, and Paradigm’s industry-leading results. 

The roundtable will be hosted by Matt Ruyter, Senior Director of Product from Paradigm. Paradigm has reviewed over $2.3 billion in total implant charges, resulting in hundreds of millions of dollars of savings for our clients.

Author:

Matt Ruyter

Senior Director of Product
Paradigm
... read more

Matt Ruyter

Senior Director of Product
Paradigm

Alan Coulter will explain the history of how the payment integrity and revenue cycle issues with Coordination of Benefits began, provide examples of current problems, and what downstream impacts can occur if COB issues are not addressed at the member, group, and claims level for both payers and providers. He will also provide some tips for healthcare insurance companies wishing to maximize their processes to assist their provider partners and vice versa when caring for patients with multiple coverages.

Author:

Alan Coulter

VP of Business Development
Performant
... read more

Alan Coulter

VP of Business Development
Performant

Innovative approaches to provider education, change in billing behaviour, and reduction in medical cost of care.

Author:

David V. Cardelle, R.Ph.

Chief Strategy Officer, SVP, Health Plan Strategy & Partnerships
Advanced Medical Strategies
... read more

David V. Cardelle, R.Ph.

Chief Strategy Officer, SVP, Health Plan Strategy & Partnerships
Advanced Medical Strategies

Discover how health plans can strategically embrace insourcing through Software-as-a-Service, regaining control of payment integrity reviews with an AI-driven platform. Join this breakout session to learn how Apixio supports teams at various readiness stages, developing configurable insourcing programs. Providing flexibility, our configurable SaaS platform is designed to meet health plans where they are in their payment integrity journey.

Author:

Brad Ross

EVP, Payment Integrity
Apixio
... read more

Brad Ross

EVP, Payment Integrity
Apixio

Author:

Amy Anzola, RN, MSN

VP, Clinical Operations
Apixio
... read more

Amy Anzola, RN, MSN

VP, Clinical Operations
Apixio

Though steps are being taken to fight healthcare fraud, there is much more that can be done. We are seeing new schemes and repeated fraud practices happening within provider networks throughout the country as we work with CMS and health plans to combat these violations. Through our network of over 550 licensed field and desktop investigators we are able to identify these situations before they become a major risk to the payors.

Ray Evans and Chandra Kuti will discuss the ever-evolving healthcare system involving state and federal regulations constantly changing along with the significant increase in utilization in the post-pandemic environment. They will review how this increase in claims volumes will effect the vulnerability for health plans and ways to identify any FWA issues that may be flying under the radar.

For over 20 years, CoventBridge Group has served as a Fraud, Waste and Abuse program integrity contractor for The Center for Medicare and Medicaid Services investigating Medical Provider FWA in Medicare, Medicaid, and commercial lines of business.

Armed with proven analytics utilizing over two decades of FWA expertise, enhanced with our proprietary algorithms and machine learning capabilities, our mission is to assist health plans in protecting their organizations from FWA through an experienced, flexible, and sensitive approach to minimizing provider abrasion, while still achieving organizational objectives.

Join our discussion on what the future holds for FWA and tactics to leverage the BIG Three --- identify – investigate – recover.  

 

Author:

Ray Evans

Vice President of Healthcare Sales
CoventBridge Group

Ray Evans is a dynamic business development executive with extensive experience working within, and servicing healthcare organizations. He holds the position of Vice President of Healthcare Sales at CoventBridge Group where he utilizes his experience to share with the industry CoventBridge’s unmatched FWA investigative solutions. His goal is to work with health plans in protecting their organization from FWA through an experienced, flexible, and sensitive approach to minimizing provider abrasion, while still achieving organizational objectives.

... read more

Ray Evans

Vice President of Healthcare Sales
CoventBridge Group

Ray Evans is a dynamic business development executive with extensive experience working within, and servicing healthcare organizations. He holds the position of Vice President of Healthcare Sales at CoventBridge Group where he utilizes his experience to share with the industry CoventBridge’s unmatched FWA investigative solutions. His goal is to work with health plans in protecting their organization from FWA through an experienced, flexible, and sensitive approach to minimizing provider abrasion, while still achieving organizational objectives.

Author:

Chandra Kuti

VP, Government Solutions Operations
CoventBridge Group
... read more

Chandra Kuti

VP, Government Solutions Operations
CoventBridge Group
10:00am

Author:

Tina Azar

Vice President, Market Leader
EXL Health

As EXL’s Vice President of Market Leadership, Tina Azar works to ensure EXL’s products and services drive to the greatest opportunities while servicing the needs of customers. Using strategic planning and thought leadership, her primary focus is to analyze insights and trends of the US Healthcare and then design and execute  comprehensive programs. She is a trusted client partner with over 22 years’ experience in claims, finance, program management, implementation and has lead operational, account management, and sales teams for Payment Integrity for over 12 years. With 12 years of experience in leading Sales and Account Management, she achieved top-in-class recognition while delivering customer and organization cost containment goals while serving as a cultural ambassador, corporate trainer, and mentor. Prior to EXL, she has worked for Change Healthcare, Emdeon and Viant.

... read more

Tina Azar

Vice President, Market Leader
EXL Health

As EXL’s Vice President of Market Leadership, Tina Azar works to ensure EXL’s products and services drive to the greatest opportunities while servicing the needs of customers. Using strategic planning and thought leadership, her primary focus is to analyze insights and trends of the US Healthcare and then design and execute  comprehensive programs. She is a trusted client partner with over 22 years’ experience in claims, finance, program management, implementation and has lead operational, account management, and sales teams for Payment Integrity for over 12 years. With 12 years of experience in leading Sales and Account Management, she achieved top-in-class recognition while delivering customer and organization cost containment goals while serving as a cultural ambassador, corporate trainer, and mentor. Prior to EXL, she has worked for Change Healthcare, Emdeon and Viant.

10:30am

Author:

Dr Priscilla Alfaro, MD, FAAP, CPC, CPMA, COC, CIC, CFE

VP Payment Integrity
Blue Cross NC
... read more

Dr Priscilla Alfaro, MD, FAAP, CPC, CPMA, COC, CIC, CFE

VP Payment Integrity
Blue Cross NC

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.

11:15am
11:45am
Track 1

Author:

Ram Davaloor

Founder and COO
Claimshark
... read more

Ram Davaloor

Founder and COO
Claimshark

Author:

Colleen Gianatasio

Director, Clinical Documentation Integrity and Coding Compliance
CDPHP

Colleen is a strategic clinical documentation, coding and compliance, and risk adjustment expert with 10+ years of experience driving increases in provider engagement. She has thoughtfully built clinical documentation improvement programs from scratch to target accurate risk scores, increases in provider satisfaction, and cost-savings.

Beyond her role at CDPHP, Colleen is also currently the president of the AAPC National Advisory Board.

... read more

Colleen Gianatasio

Director, Clinical Documentation Integrity and Coding Compliance
CDPHP

Colleen is a strategic clinical documentation, coding and compliance, and risk adjustment expert with 10+ years of experience driving increases in provider engagement. She has thoughtfully built clinical documentation improvement programs from scratch to target accurate risk scores, increases in provider satisfaction, and cost-savings.

Beyond her role at CDPHP, Colleen is also currently the president of the AAPC National Advisory Board.

How to prevent getting a flat tire!

No matter where you are on your payment integrity journey, encountering challenges are common. Reducing costs, having robust insights, and streamlining operations are key to avoiding the potholes. We'll examine these common challenges along the payment integrity journey to bring in-house key payment integrity functions and establishing a robust operation that is more predictive and preventive in nature. Additionally, we'll share best practices to galvanize the relationship between the provider and payer, creating a partnership that helps ensure payment accuracy (PEDAL methodology).

Track 2

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.

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.

12:15pm
Track 1

Author:

Lawrence M. Simon, MD, MBA, FACS

Interim Senior Medical Director
Blue Cross and Blue Shield of Louisiana (BCBSLA)

Dr. Larry Simon is the Interim Senior Medical Director and Managing Medical Director for Medical Policy and Medical Appeals for Blue Cross and Blue Shield of Louisiana (BCBSLA), where he also serves as the Medical Director for Coding and Reimbursement and Chair of the Credentialing and Medical Quality Management Committees.  He is a member of the AMA CPT Editorial Panel, serving on the Executive Committee and as Co-Chair of the Molecular Pathology Advisory Group and Genomic Sequencing Procedures Workgroup.  He also chairs the Medical Director’s Forum for both the Louisiana Association of Health Plans and the National Anti-Fraud Advisory Board of the Blue Cross and Blue Shield Association.  Prior to joining BCBSLA, Dr. Simon served in numerous leadership roles for the American Academy of Otolaryngology, the American Medical Association, the American College of Surgeons, and the Louisiana State Medical Society. 

Dr. Simon is an alumnus of Louisiana State University, Baylor College of Medicine, Rady Children’s Hospital, and the BI Moody College of Business Administration at the University of Louisiana.  A diplomate of the American Board of Otolaryngology and a Fellow of the American College of Surgeons, Dr. Simon has over 15 years of experience in Health Policy and Healthcare Reform, and he has presented over 170 lectures and seminars on these topics. 

A Rotarian, an animal rescuer, a member of multiple civic boards, and a patron of the arts, Dr. Simon enjoys spending his time outside of work serving his community, helping the animal shelters and abandoned dogs of Louisiana, and travelling and enjoying life with his wife and their family and friends.

... read more

Lawrence M. Simon, MD, MBA, FACS

Interim Senior Medical Director
Blue Cross and Blue Shield of Louisiana (BCBSLA)

Dr. Larry Simon is the Interim Senior Medical Director and Managing Medical Director for Medical Policy and Medical Appeals for Blue Cross and Blue Shield of Louisiana (BCBSLA), where he also serves as the Medical Director for Coding and Reimbursement and Chair of the Credentialing and Medical Quality Management Committees.  He is a member of the AMA CPT Editorial Panel, serving on the Executive Committee and as Co-Chair of the Molecular Pathology Advisory Group and Genomic Sequencing Procedures Workgroup.  He also chairs the Medical Director’s Forum for both the Louisiana Association of Health Plans and the National Anti-Fraud Advisory Board of the Blue Cross and Blue Shield Association.  Prior to joining BCBSLA, Dr. Simon served in numerous leadership roles for the American Academy of Otolaryngology, the American Medical Association, the American College of Surgeons, and the Louisiana State Medical Society. 

Dr. Simon is an alumnus of Louisiana State University, Baylor College of Medicine, Rady Children’s Hospital, and the BI Moody College of Business Administration at the University of Louisiana.  A diplomate of the American Board of Otolaryngology and a Fellow of the American College of Surgeons, Dr. Simon has over 15 years of experience in Health Policy and Healthcare Reform, and he has presented over 170 lectures and seminars on these topics. 

A Rotarian, an animal rescuer, a member of multiple civic boards, and a patron of the arts, Dr. Simon enjoys spending his time outside of work serving his community, helping the animal shelters and abandoned dogs of Louisiana, and travelling and enjoying life with his wife and their family and friends.

12:45pm

Learn how health plans can realize cost avoidance savings of $4.00-$7.00 PMPY (per member per year), by adopting proactive AI-based provider education, including a provider self-monitoring portal. For a mid-size health plan with 500k members, $2M-$3.5M in cost avoidance could be realized annually. As the payment integrity industry continues to ‘shift left’ through pre-claim submission efforts, it seeks AI-driven tools to maximize coding accuracy and increase savings. Health plans can benefit from automation to address resource constraints, identification of previously undetectable emerging coding issues, and collaboration and trust with their provider network. Join us to hear about our health plan partner journeys to pre-pay cost avoidance without provider abrasion. 

Track 1

Author:

Jesse Montgomery

VP of Analytics and Data Science
Codoxo
... read more

Jesse Montgomery

VP of Analytics and Data Science
Codoxo

Author:

Rena Bielinski

VP Customer Success
Codoxo
... read more

Rena Bielinski

VP Customer Success
Codoxo
  • Highlights on DRG processes and procedures for success 
  • KPIs, and Client Concerns 
  • AI - A DRG Game-changer? 
  • Case studies on DRG audits
Track 2

Author:

Katreece Baker,

VP of Clinical Operations
DRG Claims Management
... read more

Katreece Baker,

VP of Clinical Operations
DRG Claims Management

Author:

Tom Martin

PI Consultant
Independent
... read more

Tom Martin

PI Consultant
Independent
1:15pm
2:15pm

Progressing Value-Based Care Partnerships – sharing different strategies to help payers engage providers when moving to a value-based payment method and achieve a partnership.

 The transition to Value Based care is a challenging one.  Strong partnerships between payers and providers is crucial for success.  Join us as we discuss how to meet your provider partners where they are at and help them transition into value based care.  Participants will

  • Recognize the importance of assessing where providers are on their path to VBC
  • Understand what support systems should be considered for their provider networks
  • Learn best practices for removing barriers to success.

 

Track 1

Author:

Colleen Gianatasio

Director, Clinical Documentation Integrity and Coding Compliance
CDPHP

Colleen is a strategic clinical documentation, coding and compliance, and risk adjustment expert with 10+ years of experience driving increases in provider engagement. She has thoughtfully built clinical documentation improvement programs from scratch to target accurate risk scores, increases in provider satisfaction, and cost-savings.

Beyond her role at CDPHP, Colleen is also currently the president of the AAPC National Advisory Board.

... read more

Colleen Gianatasio

Director, Clinical Documentation Integrity and Coding Compliance
CDPHP

Colleen is a strategic clinical documentation, coding and compliance, and risk adjustment expert with 10+ years of experience driving increases in provider engagement. She has thoughtfully built clinical documentation improvement programs from scratch to target accurate risk scores, increases in provider satisfaction, and cost-savings.

Beyond her role at CDPHP, Colleen is also currently the president of the AAPC National Advisory Board.

2:45pm
3:00pm

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