Healthcare Payment & Revenue Integrity Congress West Agenda 2024 | Kisaco Research

Healthcare Payment & Revenue Integrity Congress West Agenda 2024

2nd Annual Healthcare Payment & Revenue Integrity Congress West
11-12 September, 2024
Luxor Hotel & Casino, Las Vegas

TAKEAWAYS INCLUDE:

In this agenda you will find sessions on topics including: 

  • Strengthening payer-provider relationships and outlining strategies for reducing provider abrasion
  • Optimizing workflows and encouraging cross functional collaboration between claims, audit, FWA, SIU, and PI teams
  • Leveraging advanced tech, such as GenerativeAI, to increase efficiencies across the healthcare value chain
  • Preventing revenue leakage by deploying intelligent automation and building proactive denial management systems
  • Discussing best practices for building payment integrity programs from the ground up at smaller health plans

To learn more about the CEU accredited sessions, click on the session title


Wednesday, 11 Sep, 2024
08:00am
09:00am
10:00am
11:00am
12:15pm

CEU Eligibility: COC, CPC, CPC-P, CPB, CPCO, CPMA, CPPM

To address the increasingly high costs and large product variation of implant devices it is important to develop an implant payment integrity program and policy. This promotes transparency between payer and provider, in addition to a more predictable implant and device spend, potentially lowering medical spend and healthcare costs. This can be achieved by utilizing evidence-based clinical guidelines, industry standard reimbursement methodologies and contracting. In addition, develop reporting and a claims review process to detect safety and quality gaps in implant usage to recoup or stop potential overpayments.

Learning Objectives:

-            Outpatient Outlier Payments for Claims

-            Credits for Replaced Medical Devices

-            Best practices for payer implant policy creation

-            Trends in inappropriate implant usage and billing

Author:

Stephanie Sjogren

Director, Coding and Provider Reimbursement
EmblemHealth/Connecticare

Stephanie Sjogren is a director of coding and provider reimbursement, working with payment integrity to ensure proper claims adjudication and to prevent fraud, waste, and abuse. Prior to joining ConnectiCare/EmblemHealth, she performed provider audits and education at a women’s healthcare group. Sjogren has also worked with physicians and staff to integrate and use electronic health record systems effectively and to stay in compliance with the Centers for Medicare & Medicaid Services’ rules and regulations. Her areas of specialty are payment integrity, auditing, and clinical documentation improvement. 

Stephanie Sjogren

Director, Coding and Provider Reimbursement
EmblemHealth/Connecticare

Stephanie Sjogren is a director of coding and provider reimbursement, working with payment integrity to ensure proper claims adjudication and to prevent fraud, waste, and abuse. Prior to joining ConnectiCare/EmblemHealth, she performed provider audits and education at a women’s healthcare group. Sjogren has also worked with physicians and staff to integrate and use electronic health record systems effectively and to stay in compliance with the Centers for Medicare & Medicaid Services’ rules and regulations. Her areas of specialty are payment integrity, auditing, and clinical documentation improvement. 

CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM

  • Establish governance strategies through varying development stages of payment integrity functions to maximize operational expenditure 

Author:

Josh Miller

Director, Payment Integrity
Prominence

Josh Miller

Director, Payment Integrity
Prominence
1:15pm
2:45pm

CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM

Strategies for identifying savings and reducing costs in pharmacy operations through:

-            Formulary design and management

-            Inventory control and standardization

-            Utilization management

-            Provider engagement

Author:

Helen Liu, Pharm.D.

VP of Pharmacy Operations
ATRIO Health Plans

Dr. Liu is the Vice President of Pharmacy Operations for the ATRIO Health Plans, where she manages and oversees all Part D-related operations. Dr Liu has an extensive background in clinical pharmacy, medication safety, managed care, and data outcome analysis. Before this role, she developed and implemented the inpatient Drug Use Management program at Kaiser Permanente.

Helen Liu, Pharm.D.

VP of Pharmacy Operations
ATRIO Health Plans

Dr. Liu is the Vice President of Pharmacy Operations for the ATRIO Health Plans, where she manages and oversees all Part D-related operations. Dr Liu has an extensive background in clinical pharmacy, medication safety, managed care, and data outcome analysis. Before this role, she developed and implemented the inpatient Drug Use Management program at Kaiser Permanente.

CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM

- Learn how to leverage your existing data to measure vendor performance and make informed decisions about in-house vs. outsourced solutions.

- Discover strategies for integrating new vendors efficiently, even with a large backlog of data.

- Gain practical frameworks to optimize vendor management and foster long-term success

Author:

Deborah Welch

Sr. Business Integration Manager
Blue Cross Blue Shield of Massachusetts

Deborah Welch

Sr. Business Integration Manager
Blue Cross Blue Shield of Massachusetts
3:45pm
4:45pm
5:15pm

CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM

Over the last few years there have been many cases of hospitals receiving inappropriate reimbursement for medical proceduresThis session will focus on the procedures associated with these cases, including diagnostic and therapeutic procedures for access sites of dialysis patients, peripheral vascular patients and a variety of surgical procedures. We will explore these cases and discuss the characteristics and scenarios that lead to inappropriate reimbursement. 

Learning Objectives: 

-Through the case study approach, examine specific types of hospital procedures that have been associated with inappropriate reimbursement 

-Explore methods for preventing, detecting and correcting errors leading to inappropriate reimbursement for these procedures. 

Author:

CJ Wolf

Professor and Asst. Program Director
Brigham Young University-Idaho

CJ Wolf

Professor and Asst. Program Director
Brigham Young University-Idaho
5:45pm
  • Speed up reimbursement and streamline day-to-day operations through efficient data exchange to enable prior authorization, claim status monitoring and identification of care gaps. 

Author:

Darren Wethers

Chief Medical Officer
ATRIO Health Plans

Darren Wethers is a board-certified internal medicine physician and certified physician executive.
He graduated from Morehouse College, Northwestern University Medical School and completed internal medicine training at Emory University School of Medicine before establishing an internal medicine practice in the St. Louis, Missouri area, becoming a “Top Doctor” Honorée several years running. Dr. Wethers was the medical staff president at SSM St. Mary’s Health Center in 2006-07 and chaired the facility’s Credentials committee 2007-11.
In 2011, Dr. Wethers began a career in administrative medicine, servings as a medical director with Coventry Health Care and Aetna, vice president of clinical operations at Blue Cross Blue Shield of Arizona and is now at Atrio Health Plans, where he serves as chief medical officer.
Dr. Wethers is a member of the American Association for Physician Leadership, Fellow of the American College of Physicians, member of Alpha Phi Alpha and Sigma Pi Phi fraternities; he is a board member and immediate past chairman for Gamma Mu Educational Services (GMES) and is a board member of Northwestern University Medical School Alumni Association, for which he serves as president-elect and co-chair of the Inclusion and Allyship committee.

Darren Wethers

Chief Medical Officer
ATRIO Health Plans

Darren Wethers is a board-certified internal medicine physician and certified physician executive.
He graduated from Morehouse College, Northwestern University Medical School and completed internal medicine training at Emory University School of Medicine before establishing an internal medicine practice in the St. Louis, Missouri area, becoming a “Top Doctor” Honorée several years running. Dr. Wethers was the medical staff president at SSM St. Mary’s Health Center in 2006-07 and chaired the facility’s Credentials committee 2007-11.
In 2011, Dr. Wethers began a career in administrative medicine, servings as a medical director with Coventry Health Care and Aetna, vice president of clinical operations at Blue Cross Blue Shield of Arizona and is now at Atrio Health Plans, where he serves as chief medical officer.
Dr. Wethers is a member of the American Association for Physician Leadership, Fellow of the American College of Physicians, member of Alpha Phi Alpha and Sigma Pi Phi fraternities; he is a board member and immediate past chairman for Gamma Mu Educational Services (GMES) and is a board member of Northwestern University Medical School Alumni Association, for which he serves as president-elect and co-chair of the Inclusion and Allyship committee.

Author:

Brittany Biggett-Heeren

Compliance Analyst
Orlando Health

Brittany Biggett-Heeren

Compliance Analyst
Orlando Health
6:30pm
7:30pm
Thursday, 12 Sep, 2024
08:30am
09:00am

Presentation on AI use cases and success stories for your implementation

Break out groups to discuss health plans' strategies and feedback to the wider group

10:00am
10:30am
11:45am
  • Biggest current opportunities for recoveries with strategies for identifying fraud attempts to drive more savings in your PI function 

Author:

Michael Devine

Director Special Investigations Unit
L.A Care

Michael Devine

Director Special Investigations Unit
L.A Care
12:30pm
1:45pm
2:30pm

CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM

In the ever-evolving landscape of healthcare, balancing cost containment with maintaining strong provider relationships is a critical challenge. This session will explore effective strategies to control costs while fostering positive, collaborative relationships with providers. Attendees will gain insights into practical approaches and best practices that align financial objectives with the goal of delivering high-quality patient care.

Learning Objectives:

-             Collaborative Approaches to Payment Integrity

-             Efficient Billing and Coding Practices

-             Provider Education and Training

-             Monitoring and Continuous Improvement  

Author:

Jonique Dietzen

Payment Integrity Director
CareOregon

With over 18 years of experience in healthcare billing and finance, I am a certified professional coder dedicated to ensuring accurate claims and proper reimbursement for providers. Having worked extensively on the provider side in finance and revenue cycle, I bring wealth of knowledge to the table, particularly in processing and payment integrity.
Throughout my career, I have gained a comprehensive understanding of billing challenges from both perspectives. This unique insight drives my commitment to improving billing practices and advocating for provider education. I continue to leverage my expertise to enhance billing processes and support providers in navigating the complexities of healthcare finance.

Jonique Dietzen

Payment Integrity Director
CareOregon

With over 18 years of experience in healthcare billing and finance, I am a certified professional coder dedicated to ensuring accurate claims and proper reimbursement for providers. Having worked extensively on the provider side in finance and revenue cycle, I bring wealth of knowledge to the table, particularly in processing and payment integrity.
Throughout my career, I have gained a comprehensive understanding of billing challenges from both perspectives. This unique insight drives my commitment to improving billing practices and advocating for provider education. I continue to leverage my expertise to enhance billing processes and support providers in navigating the complexities of healthcare finance.

Author:

Eric Carter-Nadeau

Operations Manager, Provider Network
CareOregon

Eric Carter-Nadeau

Operations Manager, Provider Network
CareOregon
3:00pm

The session will cover two drug categories and medications commonly used and current trends of fraud, waste and abuse. The four medications include GLP-1 (Ozempic/Mounjaro) and Antivirals combinations (Descovy & Biktarvy). Each drug will cover its directed use by manufacturers and common side effects, this will segue into issues of patient harm being inappropriately prescribed and its financial impact on health plans. Data analytic tactics using patient historical clinical indications to identify potential FWA providers/members and approaches to address outliers. The aftermath of inappropriately prescribing causing pharmacy inventory shortages, diversion, misbranding and counterfeit production by fraudsters for profit.

Learning Objectives:

1) Identifying counterfeit medications mentioned in presentation.

2) Implementation of provider education, recoveries and cost-saving best practices

Author:

Eric Renteria

Senior Fraud Investigator
L.A. Care Health Plan

Eric Renteria

Senior Fraud Investigator
L.A. Care Health Plan
3:30pm
3:40pm

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