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From Fragmented Data to Shared Intelligence

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From Fragmented Data to Shared Intelligence

Key discussion points:
- How state agencies and managed care organisations can build collaborative infrastructure to facilitate information exchange among MCO SIUs, oversight bodies, actuaries, and auditors
- Impact of shared information exchange on anomaly detection, high risk providers, and overpayment management
- How improved collaboration impacted managed care rate setting

Author:

Brian Dunn

Inspector General

Illinois Department of Healthcare and Family Services

Brian Dunn serves as the Inspector General for the Illinois Department of Healthcare and Family Services, where he oversees program integrity efforts for the state’s $37 billion Medicaid program. In this role, he directs criminal and civil investigations, audits, and compliance reviews, and the data analysis that supports this work. Prior to this, Brian served as First Deputy Inspector General and General Counsel for the City of Chicago’s Office of Inspector General. Before leading government oversight work, Brian’s legal career included serving as the General Counsel for the Illinois Department of Human Services and the Illinois Department of Commerce and Economic Opportunity, a litigation associate for a global law firm, and a law clerk for a federal district judge.

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Coverage Without Compromise: A New Operating Model for DRG Validation

What does a health plan actually gain when it moves from random sampling DRG claims to smart triaging them? Horizon's Ron Jones and Alaffia's TJ Ademiluyi discuss the answer: shorter review cycles, a stronger case for bringing DRG review in-house, and a rigorous test of the approach against sepsis DRG, one of the more contested determinations in claims review.

In partnership with Alaffia Health

Moderator