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
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Wednesday, 11 Sep, 202408:00am09:00am
Healthcare Fraud Initiatives in 2024
Speaker(s):
Joshua Preuss
Special Agent at U.S. Department of Health & Human ServicesOffice of Inspector General9:30amAI in Pharmacy: Revolutionizing Fraud Detection and Drug Utilization Management for Optimal Cost Savings and Payment Integrity
Sponsor(s):AMS Intelligent AnalyticsSpeaker(s):
Dave Cardelle
Chief Strategy OfficerAMS
Helen Liu, Pharm.D.
Health Plan LeaderIndependentHelen Liu, PharmD, brings 29 years of diverse pharmacy experience, blending clinical expertise, operational efficiency, technological innovation, and management across various healthcare settings.
Over the past four years, Helen has successfully led pharmacy operations at ATRIO Health Plans (Medicare), achieving significant milestones in PA/ST, FWA, MTM programs, resulting in over $4.5M in savings. She’s conducted formulary analyses to support actuary Medicare annual bid submissions, including IRA and M3P programs, collaborated with partners and the Pharmacy Benefit Manager (PBM) to identify cost-saving opportunities through formulary alternatives, biosimilars, and rebate strategies, and partnered in the RFP PBM selection process and resolved complex pharmacy-related issues through cross-departmental collaboration.
Before ATRIO, Helen spent seven years at Kaiser Permanente, where she served as Regional Assistant Director to implement hospitals Drug Use Management Program. Her efforts led to over $20 million in savings through inventory management, drug cost-saving initiatives, and the standardization of clinical content/practice guidelines.10:00amA Case Study: Achieving Spend Reduction Through Smart, Context-Aware FWA Detection and Targeted Provider Education
Session Overview
- With rising medical utilization, diminished prior auth, and greater inflationary pressures, health plans now more than ever must adopt innovation to prevent spend on fraud, waste and abuse (FWA). FWA reduction offers a huge opportunity to improve spend and member outcomes – by reducing unnecessary spend and aligning providers with best practices to avoid waste and harm. With new advances in FWA detection, plans can now improve their ability to reduce payment on FWA claims with tools that analyze patient data and provider patterns to precisely identify the services that might be wasteful or abusive.
During this case study, ATRIO Health Plans and Health at Scale will discuss the impact seen from implementing smart, context-aware FWA flagging into pre-adjudication along with a targeted provider education campaign and how the team was able to successfully drive down medical spend by 1.8% in the first year.
Learning Objectives/Key Takeaways of the Session
- Learn how ATRIO Health Plans crafted an innovative new FWA detection program and the factors that led to their substantial spend improvement
- See how new advances in FWA detection improve upon traditional systems by considering real-time context about individual patient history, provider patterns, and medical guidelines to determine if a service is appropriate
- Learn how FWA flagging in pre-adjudication can be supplemented with a targeted provider education program to align provider practices with best standards of care
Sponsor(s):Health at Scale, Corp.Speaker(s):
Jennifer Callahan
COOATRIO Health PlansJen Callahan is the President and Chief Operating Officer of ATRIO Health Plans. For over 20 years, Jen has established herself as a trusted thought leader who helped shape the managed care industry with her innovative ideas and expertise. Jen has dedicated her career almost exclusively to Medicare Advantage and Medicare Supplement programs.
Prior to joining ATRIO, she co-founded a field management organization, Keen Insurance Services, Inc. to create a provider-centric Medicare focused sales and distribution organization from the ground up. Prior to that, she held the position of Vice President, Medicare Product at Aetna, a CVS Health company where she oversaw the product development and implementation of Aetna’s entire Medicare portfolio supporting record breaking growth for the Medicare organization. Throughout her career, Jen has also held various leadership positions at Healthfirst and Elevance.
Jen received her Bachelor of Science degree from Fordham University and MBA from North Carolina State University. Jen currently resides in Waxhaw, a suburb of Charlotte, North Carolina with her husband, their three kids, tuxedo cat, Vivi and golden retriever puppy, Steve.
Zeeshan Syed
Chief Executive OfficerHealth at ScaleZeeshan serves as Health at Scale’s CEO and was a Clinical Associate Professor at Stanford Medicine and an Associate Professor with Tenure in Computer Science at the University of Michigan. He was previously part of the early stage team that launched Google[X] Life Sciences (now Verily). Zeeshan is a recipient of multiple awards including an NSF CAREER award and holds a PhD from MIT EECS and Harvard Medical School in Computer Science and Biomedical Engineering, and MEng and SB degrees in EECS from MIT.
10:30amAI Breakaway: Why to Start Implementing Today - No Need to Wait
AI is rapidly gaining traction across the healthcare space, driven by growing interest in generative AI, which can create content like text, images, and code. AI adoption, which hovered around 50 percent over the past six years, has surged to 72 percent this year. Within payment integrity, AI can help health plans escape from decades of legacy applications and outsourced high contingency fee vendors that have no incentive to automate/innovate.
Listen to industry experts discuss how to start implementing AI today and to create a balanced approach to AI adoption, one that embraces innovation while carefully managing risks.
Learning Objectives:- Initiating AI Implementation in Healthcare: Understand the practical steps and strategies for beginning AI implementation within payment integrity, moving away from outdated systems and reliance on vendors with limited incentives for innovation.
- Leveraging AI for Payment Integrity: Learn what payment integrity use cases are ready for AI deployment helping reduce dependency on legacy applications, ultimately improving efficiency and reducing costs for health plans.
- Balancing AI Innovation with Risk Management: Explore how to adopt AI in a way that maximizes innovation while carefully managing potential risks.Sponsor(s):MachinifySpeaker(s):
Prasanna Ganesan
CEOMachinify
Brandon Shelton
Senior Director, Advanced Analytics LabL.A. CareBrandon Shelton is the Senior Director of the Advanced Analytics Lab at L.A. Care, the country's largest public-option health plan, where he leads teams of Data Scientists and Data Analysts to support the health plan's various enterprise domains with machine learning solutions, program impact assessments, and business intelligence deliverables. The team's contributions towards Payment Integrity savings consistently exceeds $20M per year.
11:00am12:15pmEstablishing Implant Payment Integrity - 0.5 Credits
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
Speaker(s):
Stephanie Sjogren
Director, Coding and Provider ReimbursementEmblemHealth/ConnecticareStephanie 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.
Staffing Strategies for Payment Integrity: Who to hire, how to train and what to measure to create the best team - 0.5 CEU Credits
CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM
- Establish governance strategies through varying development stages of payment integrity functions to maximize operational expenditure
Speaker(s):
Josh Miller
Director, Payment IntegrityProminence12:45pmAI v Human: Dealing with Complex Claims
Discussion around where artificial intelligence has beneficial uses and where human expertise is necessary to achieve results- with a specific focus on complex claim review
Sponsor(s):CERISProvider Abrasion is Healthy
Description: 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.
Sponsor(s):MedReviewSpeaker(s):
Dr. Michael Menen
Chief Medical OfficerMedReview•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 Cardiology2:45pmReimbursement Red Flags From a Hospital Insider - 0.5 CEU Credits
Description: 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 procedures. This 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.
Speaker(s):
CJ Wolf
Professor and Asst. Program DirectorBrigham Young University-IdahoAn overview of Medicare Advantage– Final Rule, Future Policy Changes and Everything In-between
Speaker(s):
Richelle Marting
Director, Managed Care ContractingNorth Kansas City Hospital, Meritas Health Corporation3:15pmMetrics that Matter - How to Effectively Measure PI Performance
Sponsor(s):CarelonSpeaker(s):
Kyle Pankey
Sales & Growth LeaderCarelon SubrogationKyle 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.
Aaron Browder
PresidentCarelon SubrogationAaron 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.
Matt Monyhan
Executive Director, Operations and StrategyCarelon Subrogation
Creighton Long
Staff VP, Commercial Aligned Incentives SolutionsAnthemUnveiling Pharmacy Fraud from a Health Plan Perspective
Be the first line of defense and implement proactive strategies to identify and prevent pharmacy fraud in-house. Learn how to work with medical and pharmacy data together to further strengthen fraud detection and prevention efforts
Sponsor(s):Healthcare Fraud ShieldSpeaker(s):
Karen Weintraub
Executive Vice PresidentHEALTHCARE FRAUD SHIELDWith 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.
3:45pmInnovations in Complex and Problematic Claim Review Workflows: Leveraging the Latest Technology to Solve DRG, Specialty Drug, and E/M Claim Challenges - In Partnership with AMS
Sponsor(s):AMS Intelligent AnalyticsSpeaker(s):
John-Michael Loke
SVP, Health Plan Strategy & PartnershipsAMS4:30pmManaging and Containing Pharmacy Costs - 0.5 CEU Credits
Speaker(s):Helen Liu, Pharm.D.
Health Plan LeaderIndependentHelen Liu, PharmD, brings 29 years of diverse pharmacy experience, blending clinical expertise, operational efficiency, technological innovation, and management across various healthcare settings.
Over the past four years, Helen has successfully led pharmacy operations at ATRIO Health Plans (Medicare), achieving significant milestones in PA/ST, FWA, MTM programs, resulting in over $4.5M in savings. She’s conducted formulary analyses to support actuary Medicare annual bid submissions, including IRA and M3P programs, collaborated with partners and the Pharmacy Benefit Manager (PBM) to identify cost-saving opportunities through formulary alternatives, biosimilars, and rebate strategies, and partnered in the RFP PBM selection process and resolved complex pharmacy-related issues through cross-departmental collaboration.
Before ATRIO, Helen spent seven years at Kaiser Permanente, where she served as Regional Assistant Director to implement hospitals Drug Use Management Program. Her efforts led to over $20 million in savings through inventory management, drug cost-saving initiatives, and the standardization of clinical content/practice guidelines.5:15pmProvider-Centric FWA Prevention: See It Now To Stop It Now
Sponsor(s):4L Data IntelligenceSpeaker(s):
Clay Wilemon
Chief Executive Officer4L 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.
Greg Lyon
Senior Fraud Advisor4L 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.
5:45pmStreamlining Data Exchange for Reduced Provider Abrasion
- 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.
Speaker(s):
Darren Wethers
Chief Medical OfficerATRIO Health PlansDarren 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.CJ Wolf
Professor and Asst. Program DirectorBrigham Young University-Idaho
Jonique Dietzen
Payment Integrity DirectorCareOregonWith 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.7:30pm -
Thursday, 12 Sep, 202409:00am
AI Symposium & Fireside Chat
AI for PI (Christopher Draven, Crystal Son)
AI for Governance (Crystal Son, Simi Binning)
Revolutionizing Claims Processing: Responsible AI Strategies for Efficiency and Compliance (Fireside chat moderate by Dutch Noss)
Explore how responsible AI can revolutionize healthcare claims processing, payment integrity, and coordination of benefits. Learn actionable strategies for automating data workflows, improving claims adjudication, detecting fraud, enhancing compliance, and reducing member abrasion. This Fireside Chat will demonstrate how AI-driven insights streamline operations, reduce errors, and ensure financial and regulatory excellence.
Learning Objectives:
- Streamline Claims Processing: Leverage AI to automate workflows, improve accuracy, and reduce errors.
- Enhance Payment Integrity: Detect fraud, manage denials, and resolve overpayments efficiently.
- Optimize COB Management: Utilize AI for real-time eligibility checks, dynamic rule updates, and accurate payer sequencing.”
Session Topics:Payment IntegritySponsor(s):Alivia AnalyticsSpeaker(s):Moderator
Dutch Noss
Product & Strategy OfficerAlivia AnalyticsDutch Noss is a seasoned leader with over 25 years of expertise in Payment Integrity and Claims Processing, renowned for his pioneering approach to integrating responsible AI and machine learning into operational strategies. As Chief Product & Strategy Officer at Alivia Analytics, he drives innovations that improve accuracy within claims platforms. Dutch has held key leadership roles at various vendors and healthcare plans. A respected speaker at major healthcare conferences, he is recognized for blending deep industry knowledge with cutting-edge technology to shape the future of payment integrity.
Christopher Draven
VP Product StrategyCoverselfChristopher Draven has over 25 years experience in healthcare, starting in direct patient care.
Crystal Son
Executive Director, Enterprise Data & Analytics SolutionsHCSCCrystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC), the largest customer-owned health insurer in the United States. HCSC provides access to care nationwide through Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas as well as through its broad portfolio of companies. Crystal has 20 years of experience in deriving intelligence from data and mobilizing teams to action.
At HCSC, she leads the Strategic Initiatives & Partnerships team, which leads key programs such as Payment Integrity, Responsible AI and AI Literacy and Workforce Readiness. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.
Prior to joining HCSC in October 2022, Crystal held several roles at previous organizations, including delivery of data science advisory services, management of healthcare and government customer portfolios, and the development and launch of several new products. She began her career in data as an epidemiologist, first for the City of New York, then with Memorial Sloan-Kettering Cancer Center but has called downtown Chicago home for the last 11 years.
Simi Binning
Responsible AI LeadHCSCSimi Binning is an accomplished healthcare professional with over a decade of experience in developing and executing successful strategies that drive business growth. Currently serving as a Responsible AI lead at HCSC, her focus is on AI governance and innovative problem solving.
10:30amPayment Integrity - Market Trends - Payer-Provider Collaboration
Sponsor(s):SagilitySpeaker(s):
Mantha Subrahmanyam
VP of Payment IntegritySagility
Bob Starman
SVP of Payment Integrity SolutionsSagility11:45amFWA Trends for 2025
- Biggest current opportunities for recoveries with strategies for identifying fraud attempts to drive more savings in your PI function
Speaker(s):
Michael Devine
Director Special Investigations UnitL.A CareJoshua Preuss
Special Agent at U.S. Department of Health & Human ServicesOffice of Inspector General12:30pmProvider fraud & abuse schemes extracting billions utilizing “Catfishing” & Telemedicine
Speaker(s):
Michael Stahl
ChiropractorIndependent2:30pmCost-containment Strategies That Maintain Strong Provider Relationships - 0.5 CEU Credits
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
Speaker(s):Jonique Dietzen
Payment Integrity DirectorCareOregonWith 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.
Erik Carter-Nadeau
Operations Manager, Provider NetworkCareOregonWith over a decade in healthcare leadership, I am passionate about fostering provider engagement and delivering strategic support to improve the health of Oregonians, particularly in rural and underserved areas. As a native Oregonian, growing up in these communities across my state has provided me with unique insights into the cultural and geographic factors that influence healthcare delivery. I am committed to leveraging this understanding to enhance quality, access, and equity in healthcare for all Oregonians.
3:00pmContaining the explosion of GLP-1
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
Speaker(s):
Eric Renteria
Senior Fraud InvestigatorL.A. Care Health Plan
Angela Zigler
Special AgentFood and Drug Administration Office of Criminal Investigation3:45pm4:00pm
Jump to: Wednesday, 11 Sep | Thursday, 12 Sep