HPRI Nashville Agenda | Kisaco Research

HPRI Nashville Agenda

3rd Annual Healthcare Payment & Revenue Integrity Congress Nashville | February 5-7 2025
5-7 February, 2025
Millennium Maxwell House Nashville

Wednesday, 5 Feb, 2025
08:30am

An overview of the most significant fraud trends and payment integrity technologies and strategies going into 2025.

Payment Integrity

Author:

Kelly Bennett, JD, CFE, AHFI

Medicaid Program Integrity Chief
Agency for Health Care Administration

Kelly Bennett graduated from the University of Tampa and Florida State University College of Law.  She has been a member of the Florida Bar since 1997 and is a Certified Fraud Examiner and an Accredited Health Care Fraud Investigator.  She has worked at the Florida Agency for Health Care Administration since 2001 and has served in several roles, including as a Senior Attorney within the Medicaid Division of the Office of the General Counsel, the Assistant Bureau Chief for the Bureau of Medicaid Program Integrity, the Agency’s Medicaid
Fraud Liaison, and is currently the Chief of Medicaid Program Integrity, where she has served since July of 2014.  She is currently the President for the National Association for Medicaid Program Integrity and is an active participant in training and collaboration initiatives with the National Health Care Antifraud Association.

Kelly Bennett, JD, CFE, AHFI

Medicaid Program Integrity Chief
Agency for Health Care Administration

Kelly Bennett graduated from the University of Tampa and Florida State University College of Law.  She has been a member of the Florida Bar since 1997 and is a Certified Fraud Examiner and an Accredited Health Care Fraud Investigator.  She has worked at the Florida Agency for Health Care Administration since 2001 and has served in several roles, including as a Senior Attorney within the Medicaid Division of the Office of the General Counsel, the Assistant Bureau Chief for the Bureau of Medicaid Program Integrity, the Agency’s Medicaid
Fraud Liaison, and is currently the Chief of Medicaid Program Integrity, where she has served since July of 2014.  She is currently the President for the National Association for Medicaid Program Integrity and is an active participant in training and collaboration initiatives with the National Health Care Antifraud Association.

Author:

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

VP Payment Integrity
Blue Cross NC

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.

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

VP Payment Integrity
Blue Cross NC

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.

Author:

Prasanna Ganesan

CEO
Machinify

Prasanna Ganesan

CEO
Machinify
09:00am

Understand how interoperability fosters stronger payer-provider relationships through seamless data exchange, reducing administrative friction and ultimately improving cost containment efforts for health plans by streamlining claims processing and enhancing payment accuracy.

Explore how interoperable systems enhance risk adjustment accuracy by improving data consistency and empowering both payers and providers to address discrepancies proactively.

Payment Integrity
09:30am

This session will emphasize the importance of collaboration among stakeholders in developing and implementing consistent payment integrity metrics. Participants will explore strategies to improve data sharing, standardize measurement methodologies, and enhance fraud detection efforts.

Payment Integrity
Moderator

Author:

Katherine Brant

President
6 Degrees Health

Katherine Brant

President
6 Degrees Health

Author:

Monique Pierce

Payment Solutions & Operations
Cohere 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.

Monique Pierce

Payment Solutions & Operations
Cohere 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.

Author:

Bruce Lim

Deputy Director, Audits and Investigations
California Department of Health Care Services (DHCS)

Bruce Lim serves as the Deputy Director, Audits and Investigations, for the California Department of Health Care Services (DHCS) and is the designated Program Integrity Director for Medi-Cal, California’s Medicaid program. Mr. Lim is a certified public accountant (CPA) with over 32 years of audit and financial management experience in both the private and public sectors. Past employers include Kenneth Leventhal and Company, CPAs (Ernst & Young Kenneth Leventhal Real Estate Group), Packard Bell NEC, and the California Department of Food and Agriculture.

Bruce Lim

Deputy Director, Audits and Investigations
California Department of Health Care Services (DHCS)

Bruce Lim serves as the Deputy Director, Audits and Investigations, for the California Department of Health Care Services (DHCS) and is the designated Program Integrity Director for Medi-Cal, California’s Medicaid program. Mr. Lim is a certified public accountant (CPA) with over 32 years of audit and financial management experience in both the private and public sectors. Past employers include Kenneth Leventhal and Company, CPAs (Ernst & Young Kenneth Leventhal Real Estate Group), Packard Bell NEC, and the California Department of Food and Agriculture.

Author:

Catherine Pesek Bird

Physician Advisor
Lakeland Regional Health – Florida

Before coming to LRH, Dr. Pesek practiced as an academic cardiologist at a large Big Ten medical center, leading teams of fellows, residents, and medical students.  She provided direct patient care to cardiac patients, including transplant recipients and pregnant patients with either acquired or congenital heart disease. She worked on quality improvement programs in heart failure, sepsis, cardiac catherization, and medication adherence.

Prior to medical school, Dr. Pesek taught high school chemistry. She has written a book on understanding and determining end-of-life medical choices. She enjoys playing tennis and golf.  She is a proud alumna of the University of Notre Dame.

Catherine Pesek Bird

Physician Advisor
Lakeland Regional Health – Florida

Before coming to LRH, Dr. Pesek practiced as an academic cardiologist at a large Big Ten medical center, leading teams of fellows, residents, and medical students.  She provided direct patient care to cardiac patients, including transplant recipients and pregnant patients with either acquired or congenital heart disease. She worked on quality improvement programs in heart failure, sepsis, cardiac catherization, and medication adherence.

Prior to medical school, Dr. Pesek taught high school chemistry. She has written a book on understanding and determining end-of-life medical choices. She enjoys playing tennis and golf.  She is a proud alumna of the University of Notre Dame.

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

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

10:15am

Uncover Emerging Threats: HCFS shares insights from working with leading health plans, highlighting rising fraud schemes and patterns they’ve detected across the industry.

Prepare for 2025: Gain actionable knowledge on upcoming FWA challenges and learn strategies to strengthen your fraud detection processes, ensuring your organization stays ahead in the evolving landscape.

Payment Integrity

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. 

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. 

10:45am
12:00pm

Specialty Credits for: Core A – CPCO, CPMA

Payment Integrity

Author:

Christopher Draven

Senior Director of Payment Integrity Analytics & AI
HCSC

Christopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.

Christopher Draven

Senior Director of Payment Integrity Analytics & AI
HCSC

Christopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.

Author:

Jodi Powell

Director of Payment Integrity
HCSC

With two decades of experience in the intricate realm of medical claims, I am currently serving as a Director within the Office of Payment Integrity, where my passion for precision and accountability fuels my work. My expertise lies in both pre- and post-claim payment accuracy, ensuring that our solutions not only meet regulatory standards but also uphold the highest level of integrity for patients and providers alike.

Throughout my career, I have developed a keen eye for detail and a strategic mindset, enabling me to identify inefficiencies and implement new solutions that enhance medical cost reduction. By fostering collaboration across teams, I have led initiatives that optimize processes and improve financial sustainability, ultimately benefiting all stakeholders involved.

I pride myself on my ability to transform challenges into opportunities for growth and innovation. My commitment to excellence and adherence to ethical standards has earned me a reputation as a trusted leader in the field. I am excited to connect with professionals who share a similar vision of advancing 

Jodi Powell

Director of Payment Integrity
HCSC

With two decades of experience in the intricate realm of medical claims, I am currently serving as a Director within the Office of Payment Integrity, where my passion for precision and accountability fuels my work. My expertise lies in both pre- and post-claim payment accuracy, ensuring that our solutions not only meet regulatory standards but also uphold the highest level of integrity for patients and providers alike.

Throughout my career, I have developed a keen eye for detail and a strategic mindset, enabling me to identify inefficiencies and implement new solutions that enhance medical cost reduction. By fostering collaboration across teams, I have led initiatives that optimize processes and improve financial sustainability, ultimately benefiting all stakeholders involved.

I pride myself on my ability to transform challenges into opportunities for growth and innovation. My commitment to excellence and adherence to ethical standards has earned me a reputation as a trusted leader in the field. I am excited to connect with professionals who share a similar vision of advancing 

Enhancing Medicare Part D Fraud, Waste & Abuse Program

Payment Integrity

Author:

Helen Liu, Pharm.D.

Health Plan Leader
Independent

Helen 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.

Helen Liu, Pharm.D.

Health Plan Leader
Independent

Helen 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.

12:30pm
Payment Integrity
Payment Integrity
01:00pm
02:30pm

Showcasing one health plan’s process for creating a pre-payment system focused on reducing provider abrasion by paying more claims correctly the first time.

Specialty Credits for: Core A – CPCO, CPMA

Payment Integrity

Author:

Jordan Limperis

Data Scientist
LA Care

Highly motivated Data Scientist with a strong background in healthcare data and systems. Experienced in Inpatient Hospital and Laboratory Epic Systems, where I applied data-driven insights to improve clinical and operational efficiency. Currently, I am pursuing my career at L.A. Care, focusing leveraging advanced machine learning techniques to analyze noisy data, ensuring accuracy and efficiency in healthcare operations, particularly in payment integrity.

Jordan Limperis

Data Scientist
LA Care

Highly motivated Data Scientist with a strong background in healthcare data and systems. Experienced in Inpatient Hospital and Laboratory Epic Systems, where I applied data-driven insights to improve clinical and operational efficiency. Currently, I am pursuing my career at L.A. Care, focusing leveraging advanced machine learning techniques to analyze noisy data, ensuring accuracy and efficiency in healthcare operations, particularly in payment integrity.

Author:

Edgar Dominguez

Claims Integrity Business Manager
LA Care

Healthcare Operations expert with 20+ years of healthcare payer experience including 12+ years in Claims Administration with multiple fortune 200 companies.  I’m currently focused on implementing payment integrity initiatives aimed at cost avoidance by the use of data analytics.  I am a firm believer that data science is the wave of the future and will afford the healthcare industry with boundless opportunities to mitigate waste and reduce overall healthcare costs.

Edgar Dominguez

Claims Integrity Business Manager
LA Care

Healthcare Operations expert with 20+ years of healthcare payer experience including 12+ years in Claims Administration with multiple fortune 200 companies.  I’m currently focused on implementing payment integrity initiatives aimed at cost avoidance by the use of data analytics.  I am a firm believer that data science is the wave of the future and will afford the healthcare industry with boundless opportunities to mitigate waste and reduce overall healthcare costs.

  • In this session, we will delve into the practical applications of automation and data analytics, driving toward highest efficiency and effectiveness in your work, showcasing their benefits and limitations. We'll discuss real-life examples to illustrate the tasks AI can efficiently handle and the areas where human expertise remains crucial. Attendees will gain a comprehensive understanding of how these technologies can be leveraged within the sector, as well as insights on when to consider hiring or training staff to complement and enhance these tools.
  • Learning Objectives: Understand how key automation, including AI, can increase accuracy, consistency and throughput in your operations - Explore how shifts in inventory prioritization can deliver higher results in other insurance identification

Specialty Credits for: Core A – CPCO, CPMA

Payment Integrity

Author:

Beth Franke

Staff Vice President, Payment Integrity Coordination of Benefits
Elevance/Anthem

Beth Franke started her career in the healthcare industry over 30 years ago. During that time, she has held management and leadership positions within large healthcare organizations such as Elevance Heath, Humana, Inc. and Kindred Healthcare and served as principal consultant for the Commonwealth of Kentucky, launching the state’s first self-funded health insurance model. She has also managed multi-discipline teams within special investigations, claims, enrollment and billing, corporate applications, mobile strategy, care management and enterprise project management office. Her current role as Staff Vice President has positioned her to oversee the Coordination of Benefits organization in Payment Integrity with over 500+ associates.

Beth has a BS in Mathematics and Computer Science from Centre College. She is a Project Management Professional (PMP), a Certified Professional Coder (CPC) and earned a Master Six Sigma Black Belt (MBB) certification from Villanova University. She also serves as a certified professional coach and was recognized as an Emerging Leader at Elevance Health.

Beth and her husband line in Louisville, KY and have five adult children. She enjoys hiking, biking and traveling with her family and is also active with several volunteer organizations, providing food, shelter, and other needed services for those less fortunate.

Beth Franke

Staff Vice President, Payment Integrity Coordination of Benefits
Elevance/Anthem

Beth Franke started her career in the healthcare industry over 30 years ago. During that time, she has held management and leadership positions within large healthcare organizations such as Elevance Heath, Humana, Inc. and Kindred Healthcare and served as principal consultant for the Commonwealth of Kentucky, launching the state’s first self-funded health insurance model. She has also managed multi-discipline teams within special investigations, claims, enrollment and billing, corporate applications, mobile strategy, care management and enterprise project management office. Her current role as Staff Vice President has positioned her to oversee the Coordination of Benefits organization in Payment Integrity with over 500+ associates.

Beth has a BS in Mathematics and Computer Science from Centre College. She is a Project Management Professional (PMP), a Certified Professional Coder (CPC) and earned a Master Six Sigma Black Belt (MBB) certification from Villanova University. She also serves as a certified professional coach and was recognized as an Emerging Leader at Elevance Health.

Beth and her husband line in Louisville, KY and have five adult children. She enjoys hiking, biking and traveling with her family and is also active with several volunteer organizations, providing food, shelter, and other needed services for those less fortunate.

Author:

Thomas Ricketts

Manager, Reporting and Data Analysis
Elevance Health

Thomas is an accomplished professional with 18 years of experience in the healthcare industry, specializing in the Coordination of Benefits. Currently serving as the Manager of Reporting and Data Analysis at Elevance/Carelon. His career is marked by a commitment to leveraging data-driven insights to enhance efficiencies and drive strategic decision-making.

Thomas Ricketts

Manager, Reporting and Data Analysis
Elevance Health

Thomas is an accomplished professional with 18 years of experience in the healthcare industry, specializing in the Coordination of Benefits. Currently serving as the Manager of Reporting and Data Analysis at Elevance/Carelon. His career is marked by a commitment to leveraging data-driven insights to enhance efficiencies and drive strategic decision-making.

03:30pm
04:45pm
05:15pm

This session will bring together payers and providers to discuss the challenges and opportunities presented by healthcare mandates and electronic medical record systems. Participants will explore strategies for effective collaboration to improve patient care and reduce administrative burdens.

Payment Integrity
Thursday, 6 Feb, 2025
08:15am

(45 min – 15 min presentation, 30 min open discussion) 

No payment integrity savings benchmarks currently exist. Each health plan varies in payment integrity complexity – making it difficult to create industry standards. For the first time, HPRI has collaborated with payment integrity thought leaders to start to tackle this challenging but critical initiative. In this working session, hear how leaders are defining and calculating savings PMPMs across different programs, and share feedback to help health plans compare performance and optimize savings. Attendees will receive a post-event report with benchmarking insights.  

Payment Integrity

Author:

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

VP Payment Integrity
Blue Cross NC

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.

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

VP Payment Integrity
Blue Cross NC

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.

Author:

Monique Pierce

Payment Solutions & Operations
Cohere 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.

Monique Pierce

Payment Solutions & Operations
Cohere 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.

09:00am

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.”

Payment Integrity

Author:

Christopher Draven

Senior Director of Payment Integrity Analytics & AI
HCSC

Christopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.

Christopher Draven

Senior Director of Payment Integrity Analytics & AI
HCSC

Christopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.

Author:

Crystal Son

Executive Director of Enterprise Data Analytics Solutions
HCSC

Crystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC). She has 19 years of experience in deriving intelligence from data. 

At HCSC, she leads the Strategic Initiatives & Partnerships team, a department that focuses on cross-functional, collaborative analytics delivery on key programs such as Payment Integrity and Stakeholder Engagement, enterprise data and analytics strategy and planning, as well as design and execution of HCSC’s Responsible AI program. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.

Crystal Son

Executive Director of Enterprise Data Analytics Solutions
HCSC

Crystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC). She has 19 years of experience in deriving intelligence from data. 

At HCSC, she leads the Strategic Initiatives & Partnerships team, a department that focuses on cross-functional, collaborative analytics delivery on key programs such as Payment Integrity and Stakeholder Engagement, enterprise data and analytics strategy and planning, as well as design and execution of HCSC’s Responsible AI program. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.

Author:

Simi Binning

Responsible AI Lead
HCSC

Simi 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.

Simi Binning

Responsible AI Lead
HCSC

Simi 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.

Author:

Dutch Noss

Chief Operating Officer
Precision GX

Dutch Noss, COO of PrecisionGx is a highly versed Operations leader with 20+ years in Payment Integrity, Revenue Cycle Management, and Product Development. Dutch is an expert in the operational use of Artificial Intelligence, Machine Learning, Predictive Analysis, and Gaming Theory. Dutch’s specialties span both clinical and non-clinical audits including Contract Compliance, Duplicate Payments, IBill & DRG Review, COB, TPL, Retro-term, FWA and RAC audits in pre and post pay settings for Commercial, Medicare, and Medicaid payers.”

Dutch Noss

Chief Operating Officer
Precision GX

Dutch Noss, COO of PrecisionGx is a highly versed Operations leader with 20+ years in Payment Integrity, Revenue Cycle Management, and Product Development. Dutch is an expert in the operational use of Artificial Intelligence, Machine Learning, Predictive Analysis, and Gaming Theory. Dutch’s specialties span both clinical and non-clinical audits including Contract Compliance, Duplicate Payments, IBill & DRG Review, COB, TPL, Retro-term, FWA and RAC audits in pre and post pay settings for Commercial, Medicare, and Medicaid payers.”

10:30am
11:45am

This session will focus on:

  • California’s efforts to combat fraud, waste and abuse in Medi-Cal, California’s Medicaid program.
  • How California is exploiting available data and data sharing opportunities for purposes of Medicaid program integrity objectives.

  • A summary of program integrity best practices from the perspective of a Medicaid Program Integrity Director.

  • California’s future vision with regards to the use of data and data analytics to support its Medi-Cal fraud-control strategy.

Learning Objectives:

  • Obtain program integrity best practices that can be leveraged by the participating entity.
  • Discover new ways to exploit data to identify and develop actionable leads.

  • Performance metrics and return on investment – ways to measure success.

Specialty Credits for: Core A – All specialty except CIRCC, CPMS, CPEDC

Payment Integrity

Author:

Bruce Lim

Deputy Director, Audits and Investigations
California Department of Health Care Services (DHCS)

Bruce Lim serves as the Deputy Director, Audits and Investigations, for the California Department of Health Care Services (DHCS) and is the designated Program Integrity Director for Medi-Cal, California’s Medicaid program. Mr. Lim is a certified public accountant (CPA) with over 32 years of audit and financial management experience in both the private and public sectors. Past employers include Kenneth Leventhal and Company, CPAs (Ernst & Young Kenneth Leventhal Real Estate Group), Packard Bell NEC, and the California Department of Food and Agriculture.

Bruce Lim

Deputy Director, Audits and Investigations
California Department of Health Care Services (DHCS)

Bruce Lim serves as the Deputy Director, Audits and Investigations, for the California Department of Health Care Services (DHCS) and is the designated Program Integrity Director for Medi-Cal, California’s Medicaid program. Mr. Lim is a certified public accountant (CPA) with over 32 years of audit and financial management experience in both the private and public sectors. Past employers include Kenneth Leventhal and Company, CPAs (Ernst & Young Kenneth Leventhal Real Estate Group), Packard Bell NEC, and the California Department of Food and Agriculture.

12:15pm
12:45pm

Performance metrics and return on investment – ways to measure success.

Payment Integrity

Author:

Rae A. McIntee, DDS, MD, MBA, FACS, CPE

Medical Director Payment Integrity and Special Investigations
Blue Cross and Blue Shield of Louisiana

Rae A. McIntee, DDS, MD, MBA, FACS, CPE

Medical Director Payment Integrity and Special Investigations
Blue Cross and Blue Shield of Louisiana
1:15pm
2:45pm

This presentation will delve into the latest trends and tactics employed by fraudsters, providing actionable insights to safeguard your organization. Attendees will gain a comprehensive understanding of the evolving threat landscape, learn to identify red flags and implement effective prevention strategies.

Payment Integrity
03:30pm
04:00pm

This session will explore how to identify and prevent opioid-related fraud within pharmacy claims, focusing on strategies to combat the opioid crisis while safeguarding healthcare resources.

Payment Integrity
Moderator

Author:

Helen Liu, Pharm.D.

Health Plan Leader
Independent

Helen 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.

Helen Liu, Pharm.D.

Health Plan Leader
Independent

Helen 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.

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.

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.

Author:

Eric Branson

Special Agent
Department of Health and Human Services, Office of Inspector General

Eric Branson is a special agent with the Department of Health and Human Services Office of Inspector General. Eric started investigating healthcare fraud in August 2011, spending time at both a Medicare and Medicaid contractor as well as working for the US Attorney's Office in the Middle District of Tennessee prior to becoming an agent. During that time, he has investigated fraud committed against both government and commercial insurance payors perpetrated by doctors, laboratories, pharmacies, home health agencies, durable medical equipment suppliers, and other healthcare providers. Eric graduated from Middle Tennessee State University with a Master's degree in Criminal Justice.

Eric Branson

Special Agent
Department of Health and Human Services, Office of Inspector General

Eric Branson is a special agent with the Department of Health and Human Services Office of Inspector General. Eric started investigating healthcare fraud in August 2011, spending time at both a Medicare and Medicaid contractor as well as working for the US Attorney's Office in the Middle District of Tennessee prior to becoming an agent. During that time, he has investigated fraud committed against both government and commercial insurance payors perpetrated by doctors, laboratories, pharmacies, home health agencies, durable medical equipment suppliers, and other healthcare providers. Eric graduated from Middle Tennessee State University with a Master's degree in Criminal Justice.

Friday, 7 Feb, 2025
09:30am

In this interactive workshop, attendees will review and discuss their own experiences with AI, data analytics, and fraud prevention strategies covered during the conference. The session will focus on how these tools can be used for early issue detection and claims management, while also addressing new federal rules and fraud trends shared by regulatory experts. Walk away with actionable insights tailored to your organization’s challenges.

In collaboration with 4L Data Intelligence.

Payment Integrity

Author:

Christopher Draven

Senior Director of Payment Integrity Analytics & AI
HCSC

Christopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.

Christopher Draven

Senior Director of Payment Integrity Analytics & AI
HCSC

Christopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.

Author:

Simi Binning

Responsible AI Lead
HCSC

Simi 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.

Simi Binning

Responsible AI Lead
HCSC

Simi 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.

Author:

Crystal Son

Executive Director of Enterprise Data Analytics Solutions
HCSC

Crystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC). She has 19 years of experience in deriving intelligence from data. 

At HCSC, she leads the Strategic Initiatives & Partnerships team, a department that focuses on cross-functional, collaborative analytics delivery on key programs such as Payment Integrity and Stakeholder Engagement, enterprise data and analytics strategy and planning, as well as design and execution of HCSC’s Responsible AI program. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.

Crystal Son

Executive Director of Enterprise Data Analytics Solutions
HCSC

Crystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC). She has 19 years of experience in deriving intelligence from data. 

At HCSC, she leads the Strategic Initiatives & Partnerships team, a department that focuses on cross-functional, collaborative analytics delivery on key programs such as Payment Integrity and Stakeholder Engagement, enterprise data and analytics strategy and planning, as well as design and execution of HCSC’s Responsible AI program. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.

Author:

Clay Wilemon

Chief Executive Officer
4L 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. 

Clay Wilemon

Chief Executive Officer
4L 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. 

10:30am
11:00am

Exchange in conversations with other attendees to understand how enhanced data exchange can streamline workflows, reduce administrative burdens, and improve overall efficiency off the back off the payer-provider panel on Day 1. Review the role of interoperability and data sharing in improving fraud detection, claim accuracy, and cost management that were discussed throughout the event.

Medical Cost Containment

Author:

Edward Marx

Chief Executive Officer
Marx Advisory

The youngest child of Holocaust survivors, Ed moved to the United States at age 10. At 16, he served as a medical clinic janitor where he discovered his healthcare calling. Ed took successive positions as combat medic, anesthesia tech, strategic planner and technology manager. He quickly learned how the convergence of clinical, business and digital saved lives. His passion ignited, he jumped feet first into technology and operations in the C-Suite of Cleveland Clinic, NYC Health & Hospitals, Texas Health Resources and University Hospitals.

Intermixed, Ed served the supplier side as well. He was CEO for consulting firm Divurgent, global CDO for Tech Mahindra Health & Life Sciences and CIO of the Advisory Board. Concurrently, he served 15 years as an Army combat engineer officer and combat medic. Today, Ed is focused on his own advisory practice.

Ed does a fair amount of speaking, writing and podcasting. He authored healthcare bestsellers including “Voices of Innovation” and “Healthcare Digital Transformation”. He is currently writing a book for Mayo Clinic on “Patient Experience” and “Voices of Innovation - Payers”. His podcast “DGTL Voices” is “Top 3%” globally. His Blog, CEO Unplugged, surpassed 1M views. Ed recently started a YouTube channel to expand his audience.

Most importantly, Ed is husband to Simran who holds a Doctor of Nursing (DNP). They love to dance and climb mountains. They have 5 grown children and 4 grandchildren. To stay fit, he is captain of TeamUSA Triathlon.

For more career information you can find me:

Twitter https://twitter.com/marxtango

LinkedIn https://www.linkedin.com/in/edwardmarx/

Website https://www.marxadvisory.com/

YouTube https://www.youtube.com/@EdwardMarx

Edward Marx

Chief Executive Officer
Marx Advisory

The youngest child of Holocaust survivors, Ed moved to the United States at age 10. At 16, he served as a medical clinic janitor where he discovered his healthcare calling. Ed took successive positions as combat medic, anesthesia tech, strategic planner and technology manager. He quickly learned how the convergence of clinical, business and digital saved lives. His passion ignited, he jumped feet first into technology and operations in the C-Suite of Cleveland Clinic, NYC Health & Hospitals, Texas Health Resources and University Hospitals.

Intermixed, Ed served the supplier side as well. He was CEO for consulting firm Divurgent, global CDO for Tech Mahindra Health & Life Sciences and CIO of the Advisory Board. Concurrently, he served 15 years as an Army combat engineer officer and combat medic. Today, Ed is focused on his own advisory practice.

Ed does a fair amount of speaking, writing and podcasting. He authored healthcare bestsellers including “Voices of Innovation” and “Healthcare Digital Transformation”. He is currently writing a book for Mayo Clinic on “Patient Experience” and “Voices of Innovation - Payers”. His podcast “DGTL Voices” is “Top 3%” globally. His Blog, CEO Unplugged, surpassed 1M views. Ed recently started a YouTube channel to expand his audience.

Most importantly, Ed is husband to Simran who holds a Doctor of Nursing (DNP). They love to dance and climb mountains. They have 5 grown children and 4 grandchildren. To stay fit, he is captain of TeamUSA Triathlon.

For more career information you can find me:

Twitter https://twitter.com/marxtango

LinkedIn https://www.linkedin.com/in/edwardmarx/

Website https://www.marxadvisory.com/

YouTube https://www.youtube.com/@EdwardMarx

12:00pm

Jump to: Day 1 | Day 2 | Day 3

Other events you might be interested in:

Medical Cost Containment Summit

Healthcare Payment & Revenue Integrity Congress