In partnership with AMPS.
Mark Noel
SVP, GM ClaimInsight
Advanced Medical Pricing Solutions
Jake Weihrauch
VP of Sales, ClaimInsight
Advanced Medical Pricing Solutions
In partnership with Optum
Tisha Holden
Market President
Optum
Serving as Market President at Optum, Tisha has spent more than 25 years at the forefront of health plan innovation, helping clients build strategic, comprehensive programs to address their toughest challenges and achieve financial health and operational excellence at scale.
Clinical data is becoming the foundation that enables payment integrity to evolve from payment recovery to prevention, impacting payment accuracy and broader healthcare affordability goals. But this shift requires transforming how clinical data, AI, PI processes and people are aligned. Through a case study example, payment integrity and clinical data leaders from BCBS of South Carolina will discuss an innovative approach to using real-time clinical data to generate their own ‘claims’ to guide pre-payment reviews. Key topics will include:
- Developing a roadmap for effective clinical data integration into pre-pay PI decision making and workflows
- Reimagining the PI process – new capabilities, collaboration, and upscaling staff
- Lessons learned while shifting from traditional post-pay operations and governance
In partnership with Claritev
Moderator
Marla Ludacka-Dragovich
Vice President of Payment Integrity Operations
Claritev
Marla Ludacka-Dragovich is Vice President of Payment Integrity Operations at Claritev, where she leads Payment & Revenue Integrity Services both Pre- and Post-Payment. Her leadership spans Advanced Code Editing, Itemized Bill Review, DRG Validation, Specialty Services, Coordination of Benefits, Data Mining, End Stage Renal Disease, and Medicare Secondary Payer programs. She also supports Clinical Negotiations and drives innovation across manual code editing, analytics, and product development.
With more than 25 years of healthcare experience, primarily within the Blue Cross and Blue Shield system, Marla brings deep expertise in network operations and payment integrity. She is passionate about advancing innovative solutions, improving operational performance, and delivering meaningful value across the healthcare ecosystem. Marla holds a Bachelor of Science in Finance and Economics from Elmhurst University.
Outside of work, Marla enjoys boating, golfing, biking, hiking, tennis, pickleball, and reading, and is the proud mother of two sons.
Panelists
Karen S. Campbell
Senior Director, Payment Integrity, Payor Innovations Division
BlueCross BlueShield of South Carolina
Karen Campbell is Senior Director for Payment Integrity at BlueCross BlueShield of South Carolina. She has been part of Payment Integrity team since early inception and helped develop core team capabilities from data mining to policy application and clinical support. Her recent focus has been on solution deployment that expands system edits, provider education and increases clinical claim reviews both pre-pay and post-pay. She has worked closely with Operations, Decision Support and Medical Affairs to help take new policies, technology and edits from inception to deployment throughout the organization.
Autumne Smith
Director, Connected Health Services
BlueCross BlueShield of South Carolina
Autumne Smith is the Director of Connected Health Services at BlueCross BlueShield of South Carolina, where she leads enterprise initiatives focused on interoperability, clinical data exchange, regulatory readiness, and connected health innovation. With more than 10 years of experience across health care data, technology, governance, and operations, Autumne brings together business strategy, technical execution, and compliance rigor to advance how health information is exchanged, governed, and used to improve outcomes.
Autumne earned her Master’s in Health Information Technology from the University of South Carolina and her Bachelor of Art in Psychology from Winthrop University.
Payment integrity is evolving from a downstream claims audit function to a proactive, critical lever for upstream cost avoidance. Payment integrity leaders note that ‘shifting left’ can cut administrative duties by at least 10-15%, in addition to improving provider abrasion. But evolving to cost avoidance not only requires a shift in mindset, but an evolution in how data, AI tools, and cross-functional collaboration are used to enable proactive decision making.
- Case studies: Critical strategies for launching pre-pay programs and measuring ROI
- How AI is expanding pre-pay capabilities and required governance
- Rethinking the impact and attribution of provider education initiatives
In partnership with Optum
Moderator
Alex Berman
Vice President, Payment Integrity
Optum
Alex Berman is a healthcare executive specializing in client engagement, product strategy and growth across payer markets. He partners with health plans to align client needs with innovative solutions that improve performance and continue to remove waste from the healthcare system.
Panelists
David Kagan
Chief of Healthcare Delivery
LA Care
Linde Winton
Senior Director of Operations
Provider Partners Health Plan
Linde Winton is the Senior Director of Operations for Provider Partners Health Plan and a healthcare executive with nearly four decades of experience in managed care, Medicare Advantage, compliance, claims administration, and payment integrity. Throughout her career, she has led operational, compliance, quality assurance, audit, and Special Investigation Unit (SIU) programs for health plans, third-party administrators, and healthcare technology organizations.
Linde has extensive expertise in payment integrity, fraud, waste and abuse prevention, regulatory compliance, claims operations, vendor oversight, and healthcare analytics. She has developed and implemented enterprise-wide audit and investigation programs, directed complex regulatory initiatives, overseen large-scale operational improvements, and partnered with organizations to strengthen payment accuracy while maintaining compliance with evolving federal and state requirements.
Recognized for her ability to bridge the gap between operational execution and regulatory oversight, Linde brings a practical, real-world perspective to healthcare payment integrity. Her work has focused on identifying emerging risks, improving claims accuracy, leveraging data analytics to uncover hidden issues, and implementing sustainable solutions that drive measurable results. As a frequent collaborator across operations, compliance, and payment integrity teams, she is passionate about helping organizations navigate today's increasingly complex healthcare environment while protecting the integrity of healthcare payments.
Philip David
Director, Fraud, Waste and Abuse Special Investigations Unit
WellSense Health Plan
The payment integrity vendor landscape has expanded rapidly, with plans now juggling specialist partners across pre-pay, post-pay, DRG validation, COB, FWA, clinical review, and an ever-growing list of AI-enabled point solutions. While each vendor promises incremental savings, the cumulative cost of sourcing, contracting, onboarding, integrating, and reconciling reporting across a sprawling stack is becoming a payment integrity problem in its own right. This panel brings together PI leaders who have wrestled with rationalising their vendor ecosystems to share practical approaches for building a leaner, better-orchestrated, and easier-to-manage vendor stack without losing savings yield.
- How to evaluate and source new vendors efficiently, including which proof points and pilot structures actually predict in-production performance
- Designing a waterfall and integration model that minimises duplicate findings, claim leakage, and operational drag across multiple vendors
- Consolidating vendor reporting and KPIs into a single view so PI leaders can defend total program value to senior leadership
Alejandro Rincon
Associate Principal
ZS Associates
Alejandro Rincon is an Associate Partner in ZS's Health Plan and Provider practice. He has over a decade of experience solving complex challenges across strategy, analytics, and AI. His work focuses on health plan payment integrity, operating model transformation, and data-driven decision making.
Tom Martin
VP Payment Integrity
AmeriHealth Caritas
Eliot Balistreri
Director, Partner Strategy and Performance
Elevance
Eliot Balistreri is a healthcare payment integrity leader with experience building and optimizing vendor and partner programs across the claims lifecycle. His work includes vendor evaluation and strategy, performance management, implementation, and financial planning & analysis.
Jason May
Director, Payment Integrity Strategy & Operations
HCSC
Jason May is Director of Payment Integrity Strategy & Operations at HCSC, where he leads the organization's payment integrity strategy, operational performance, and PI initiatives. His experience spans payment integrity analytics, vendor management, and the development and insourcing of payment integrity capabilities.
Jeff Baker
Director of Payment Integrity
Medical Mutual
Kim Hoang
Ex-Director, Payment Integrity
Molina
Kim Hoang is a payment integrity leader with over ten years of experience developing and operating health plan payment integrity programs. Drawing on her experience leading payment integrity functions at Molina Healthcare and advising health plans on strategic initiatives, she brings a practical perspective on vendor management, payment accuracy, and operational transformation.
Melissa McCabe
Payment Integrity Program Lead
Quartz
Code updates. Site-of-service rule changes. Specialty drug billing classifications. Telehealth policy still being written. Coding technology evolving. The environment that edit programs have to keep up with in 2026 is more complex than it has ever been, and an annual review cycle is not enough. This session looks at what a well-governed, modern, continuously maintained edit program looks like in practice, where the most costly gaps tend to open and how technology can keep your plan ahead.
- How to build an edit governance process that keeps pace with frequent policy changes across multiple lines of business
- Where the highest-risk edit gaps are opening right now and how to prioritise closing them without expanding every programme at once
- How to defend edits in provider disputes when the underlying policy they are based on is itself in transition
In partnership with Shift Technology
Moderator
Jesse Montgomery
Head of US Healthcare Customer Success & Value Engineering
Shift Technology
Leading Healthcare Customer Success and Value Engineering, my mission has been focused on transforming customer engagement through a fusion of industry knowledge, data science, and personalized service strategies. Leverage my strategic partnerships to advance collaborative successes, resulting in the development of creative and innovative healthcare solutions and capability expansion for Shift Technology focused on payment integrity, ultimately enhancing our customer commitments and financial targets.
Panelists
Dr. Priscilla Alfaro
Strategic Advisor, Cost Containment & Payment Transformation
Dr. Priscilla Alfaro is a seasoned healthcare professional with extensive experience in executive medical management, fraud prevention, and healthcare analytics. A certified medical coder, fraud examiner, and auditor, she has a proven track record of improving healthcare efficiency and preventing fraud, waste, and abuse across various roles and affiliations, including the Texas HHS and Anthem.
State program integrity teams, MCO SIUs, and partners are moving beyond static reporting toward real-time collaboration models that improve visibility and coordination. This panel explores how shared data and centralized platforms are enabling earlier detection, stronger oversight, and more aligned decision-making across the ecosystem.
- How a centralized portal enables real-time information exchange between OIGs, MCOs, SIUs, and partners
- The impact of shared intelligence on identifying high-risk providers and managing overpayments
- How improved collaboration is influencing actuarial processes and managed care rate setting
In partnership with HMS, Gainwell
Moderator
Dr Gary Call
Chief Medical Officer
HMS
Dr. Gary Call is a board-certified family physician and senior healthcare executive with extensive experience in managed care operations and payment integrity.
Dr. Call is nationally recognized for his leadership in payment integrity and FWA prevention, including advanced analytics, clinical review strategies, and technology-enabled solutions that protect both government and commercial payer programs from improper payments and emerging integrity risks.
As Chief Medical Officer at HMS, Dr. Call oversees Payment Integrity, Care Management, Clinical Analytics, and Population Health Solutions, driving innovation and clinical programs that improve outcomes, strengthen program integrity, and support the financial sustainability of state healthcare programs.
Panelists
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.
James Vanderberg
Director, Special Investigations Unit
HCSC
James Vanderberg is a Director at HCSC with seven years of experience in the organization’s Special Investigations Department. He currently oversees fraud, waste, and abuse (FWA) operations for government programs.
Prior to joining HCSC, James served with the U.S. Department of Labor, Office of Inspector General, where he retired as the Special Agent in Charge for the Chicago Region. In this role, he led administrative, civil, and criminal investigations involving fraud, waste, and abuse across medical, unemployment, and job training benefits and grants.
Kevin O'Donnell
Director of the Division of Program Integrity
D.C. Department of Health Care Finance
Kevin O’Donnell is the Director of the Division of Program Integrity for the D.C. Department of Health Care Finance, the District’s Medicaid agency. He has served in that role since November 2021. In that capacity, he oversees the Medicaid agency’s Fraud, Waste, and Abuse activities, coordinating and supervising audits and investigations of Medicaid enrolled providers. To ensure the Medicaid program is effectively rooting out FWA, Mr. O’Donnell collaborates with public and private partners, including law enforcement agencies, regulatory agencies, Managed Care Organizations, and others.
Prior to becoming the Director of the DPI, Mr. O’Donnell spent 7 years as an Attorney-Advisor in DHCF’s Office of the General Counsel, where he defended the agency in administrative appeals before the D.C. Office of Administrative Hearings. Mr. O’Donnell is a graduate of the George Washington University School of Law and a native Washingtonian.
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
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.