Join us at the 7th Annual Healthcare Payment & Revenue Integrity Congress returning in Nashville!
Whether you’re looking for vendors with proven ROI or insourcing strategies from health plan leaders, this event has it all. Explore AI-driven solutions for improving data analytics, reducing FWA, and enhancing claims accuracy. Network with peers and collaborate with providers to drive efficiency and financial success for your plan!
WHY HPRI
Whats New for 2025?
Bigger, better audience
With now 3 separate curated topics, we aim to unite payers and providers across everything finance. Covering the liked of payment integrity and risk adjustment from the health plan side and revenue cycle management on the provider side, we include all aspects of payer-provider collaboration across healthcare finance
Facilitated Networking
Trialled during our Vegas conference, returning even bigger in Nashville! We’re helping you keep up to date with solutions on the market and curating the conversations you have with vendors so you meet those who can really help your organisations save more.
More Innovation
We understand that many health plans don’t have the budget for new vendors, so we’re recruiting the best in the business to tell you how you can do it yourself. More insourcing, data analytics, AI use cases to help you improve your cost containment.
2023 Highlights
2
Main Event Days
35+
Industry Leading Speakers
180+
Industry Experts
15+
Dedicated Networking Hours
POST EVENT REPORT
Are you interested in learning about the key takeaways from HPRI South in Miami, Feb 2024? Download the post event report to:
- View the list of companies in attendance
- Hear what health plans thought of the event
- Read takeaways on the biggest priorities for the market
- Discover what is next in the series
DON'T TAKE OUR WORD FOR IT
This was a great event to bring together all of the key players of payment integrity to collaborate and learn from one another.
Senior Manager of Payment Integrity Office, Florida Blue
Outstanding opportunity to collaborate with other medical directors and vendors. The small forum allowed for more indepth discussions in an informal environment.
Medical Director Payment Integrity and Special Investigations, Blue Cross and Blue Shield of Louisiana
This event was great for networking. There were some of the best vendors in the industry, and there was a good mix of representation from the payer side.
Associate Director, Payment Integrity, UMR
The insights gained from HPRI South spotlights key changes in the industry and provides a roadmap for developing a strategy for success for our company. The domain expertise, decision makers in attendence, and ability to have meaningful exchange of ideas, makes this the an event that PI amd RCM professionals must attend.
Chief Strategy Officer, AMS
It is a great community and a great meeting. I would encourage anybody in the PI space to get out here.
Interim Senior Medical Director, Blue Cross and Blue Shield
How To Get Involved
Partner With Us
Partner with us to elevate your brand, and make valuable new connections. Subject to availability, we offer opportunities for thought leadership, branding, and facilitated networking.
Please contact our Partnerships Director, Harry Ludbrook, for more information. [email protected].
Register your free place
Step into interactive discussions and engaging presentations on the key challenges and opportunities presented by payment companies.
Healthcare Payers & Providers can attend for free.
Featured Speakers
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.
David Flannery
Director of Telegenetics and Digital Genetics
Cleveland Clinic
David Flannery is a "pioneer" in telemedicine, having started telegenetics clinic in 1995 in Georgia. He’s currently the Director of Telegenetics and Digital Genetics at Cleveland Clinic. He has expertise with ICD-10 coding and CPT codes. He oversaw the revenue cycle management for the 300+ physician practice group at the Medical College of Georgia. He served on the American Medical Association's Digital Medicine Payment Advisory Group, developing new CPT codes for telemedicine and digital medicine.
Dr. Ahmad Kilani MD, MBA, MLS, MSIT, CHCQM-PHYADV, FACP, FACHE
Medical Director
Cleveland Clinic
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.
Rae A. McIntee, DDS, MD, MBA, FACS, CPE
Medical Director Payment Integrity and Special Investigations
Blue Cross and Blue Shield of Louisiana
Kelly Springmann
Provider Enablement & Product Development
Florida Blue
26% of health plans identify access to quality data as their biggest challenge
Understand the several critical points for payers in the healthcare sector as they navigate the complexities and opportunities of 2024 considering the evolution of payment integrity, opportunities with AI implementation and impact of financial pressures.
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"The HPRI event's are great. I enjoy the presentations, opportunity to meet with vendors and network with other payers and providers."Monique Pierce, Head of Payment Integrity joined Devoted Health in 2020 with the goal of building the first ever integrated Payment Integrity Program. She shares her experiences, wins and challenges at the HPRI events. -
Navigating the Payment Integrity Vendor landscape with usThe ultimate guide to who’s who in the payment integrity vendor space – to help you choose the best option for your business. -
Looking for tips and tricks on how to develop your payment integrity strategy in 2024?We met with leader Dr. Michael Seavers from Harrisburg University of Science and Technology on where to start when it comes to addressing your current strategy to ensure you are working efficiently.
How To Get Involved
Partner With Us
Partner with us to elevate your brand, and make valuable new connections. Subject to availability, we offer opportunities for thought leadership, branding, and facilitated networking.
Please contact our Partnerships Director, Harry Ludbrook, for more information. [email protected].
Register Your Free Place
Step into interactive discussions and engaging presentations on the key challenges and opportunities presented by payment companies.
Healthcare Payers & Providers can attend for free.
OUR COMMUNITY OF PAYERS AND PROVIDERS
Step into interactive discussions and engaging presentations on the key challenges and opportunities presented by payment companies today:
OUR PARTNERS
AUDIENCE BREAKDOWN
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Healthcare Payers/ Insurance Companies40%
-
Healthcare Providers20%
-
Payment Integrity Vendors30%
-
Claims Processing10%
OUR SELECTION COMITTEE
Brannon Morisoli
Director
SWK Holdings
Mr. Morisoli joined SWK Holdings as a Senior Analyst in March 2016. Prior to joining SWK, he was an Investment Analyst and Portfolio Manager for a family office that invested in equities, fixed income, real estate, and alternative investments. Prior to that, he was an Investment Analyst for Presidium Group, a real estate private equity firm, where he played an integral role in closing over $100mm in transactions. Mr. Morisoli began his career at Neurografix, a startup medical technology company in Santa Monica, CA that was doing groundbreaking work in the MRI imaging of peripheral nerves. While with Neurografix, he was published in two leading neurology journals. Brannon graduated from UCLA with a B.S., was awarded a fellowship and graduated from the University of Notre Dame with an M.B.A, and was awarded a Samson Fellowship from the University of Wisconsin Law School, where he graduated with a J.D. Mr. Morisoli is an inactive member of the State Bar of Wisconsin
Thomas Busby
Vice President
Outcome Capital
Thomas Busby is a Vice President and has been with Outcome Capital since 2015. He focuses on medical technology, digital health and life science services segments with particular interest in innovative life science companies that deliver patient impact by leveraging novel approaches. Thomas is driven by the desire to identify disruptive technologies and services that require unique strategic thought and assistance to realize their full market potential. Thomas has been published in leading life science journals Life Science Leader and The Pharma Letter, and also serves on the board of HealthTech Build, a Boston-based digital health innovation group.
Prior to his career in life-science investment banking, Thomas pursued his passion for the public service and non-profit sectors working in a variety of leadership and management positions, and at one time held a Massachusetts teaching license.
Thomas completed his MBA at Suffolk University’s Sawyer Business School on full academic scholarship where he was President of the school’s Graduate Business Association and class speaker at graduation. Prior, he completed a BS in Philosophy with Honors from Suffolk’s College of Arts & Sciences. Committed to giving back, Thomas is currently the President of the College of Arts & Sciences Alumni Board of Directors. Thomas is a FINRA Registered Securities Representative holding his Series 79 and 63.
Robert Crousore
Managing Partner
Health Frontier Ventures
Robert has 28 years of experience in the health care products and
services industry. Crousore is a serial entrepreneur with multiple
successful product and services company exits. His experience spans
the entire business enterprise including Sales, Marketing, Operations,
Product Innovation and, most recently M & A.
Highlights Include:
- Has successfully managed a global commercial organization in the wound care business.
- Has a number of patent credits for products in the wound care industry.
- Sits on multiple boards of healthcare technology companies.
- His passion is creating meaningful changes in patient care by combining great products with great teams that are focused on empowering improved clinical and financial outcomes.
Brannon Morisoli
Director
SWK Holdings
Mr. Morisoli joined SWK Holdings as a Senior Analyst in March 2016. Prior to joining SWK, he was an Investment Analyst and Portfolio Manager for a family office that invested in equities, fixed income, real estate, and alternative investments. Prior to that, he was an Investment Analyst for Presidium Group, a real estate private equity firm, where he played an integral role in closing over $100mm in transactions. Mr. Morisoli began his career at Neurografix, a startup medical technology company in Santa Monica, CA that was doing groundbreaking work in the MRI imaging of peripheral nerves. While with Neurografix, he was published in two leading neurology journals. Brannon graduated from UCLA with a B.S., was awarded a fellowship and graduated from the University of Notre Dame with an M.B.A, and was awarded a Samson Fellowship from the University of Wisconsin Law School, where he graduated with a J.D. Mr. Morisoli is an inactive member of the State Bar of Wisconsin
Thomas Busby
Vice President
Outcome Capital
Thomas Busby is a Vice President and has been with Outcome Capital since 2015. He focuses on medical technology, digital health and life science services segments with particular interest in innovative life science companies that deliver patient impact by leveraging novel approaches. Thomas is driven by the desire to identify disruptive technologies and services that require unique strategic thought and assistance to realize their full market potential. Thomas has been published in leading life science journals Life Science Leader and The Pharma Letter, and also serves on the board of HealthTech Build, a Boston-based digital health innovation group.
Prior to his career in life-science investment banking, Thomas pursued his passion for the public service and non-profit sectors working in a variety of leadership and management positions, and at one time held a Massachusetts teaching license.
Thomas completed his MBA at Suffolk University’s Sawyer Business School on full academic scholarship where he was President of the school’s Graduate Business Association and class speaker at graduation. Prior, he completed a BS in Philosophy with Honors from Suffolk’s College of Arts & Sciences. Committed to giving back, Thomas is currently the President of the College of Arts & Sciences Alumni Board of Directors. Thomas is a FINRA Registered Securities Representative holding his Series 79 and 63.
Robert Crousore
Managing Partner
Health Frontier Ventures
Robert has 28 years of experience in the health care products and
services industry. Crousore is a serial entrepreneur with multiple
successful product and services company exits. His experience spans
the entire business enterprise including Sales, Marketing, Operations,
Product Innovation and, most recently M & A.
Highlights Include:
- Has successfully managed a global commercial organization in the wound care business.
- Has a number of patent credits for products in the wound care industry.
- Sits on multiple boards of healthcare technology companies.
- His passion is creating meaningful changes in patient care by combining great products with great teams that are focused on empowering improved clinical and financial outcomes.
PREVIOUS INDUSTRY LEADING SPEAKERS
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
Lourdes Centeno Fanjoy
Subject Matter Expert
Independent
With over 15 years of experience in revenue cycle management, compliance, payer policy advising, and executive presentations, Lourdes is a results-oriented leader dedicated to optimizing operational strategies and driving corporate success. Her resource allocation, process redesign, and capacity planning skills enable her to enhance profit margins and achieve strategic goals. Lourdes brings expertise in Medicare and Medicaid reimbursement policies, ensuring effective and compliant financial practices.
REGISTER YOUR INTEREST
To be kept up to date on developments, please complete the form.
Day One: Wednesday, 5 Feb, 2025
Registration – Payer/Provider Speed Networking Sessions
8:30 – 9:30
Payment Integrity Overview – A look at 2025
An overview of the most significant fraud trends and payment integrity technologies and strategies going into 2025.
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.
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.
9:30 – 10:45
Collaborating for Consistent Payment Integrity Metrics
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.
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.
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.
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.
10:45 – 12:00
One-To-One Structured Networking
12:00 – 1:00
Payment Integrity Basics – Getting Started
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.
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 (FWA)
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.
1:00 – 2:30
One-To-One Structured Networking
2:30 – 3:30
Harmonizing Tech and Talent: Revolutionizing COB Operations
- 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
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.
A Journey through the Development and Deployment of a Pre-Payment Modelling System
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.
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.
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.
3:30 – 4:45
One-To-One Structured Networking
4:45 – 5:15
Session in Partnership with Healthcare Fraud Shield
5:15 - 6:00
The Payer-Provider Panel: Mandates, EMR Systems and Collaboration
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.
Lourdes Centeno Fanjoy
Subject Matter Expert
Independent
With over 15 years of experience in revenue cycle management, compliance, payer policy advising, and executive presentations, Lourdes is a results-oriented leader dedicated to optimizing operational strategies and driving corporate success. Her resource allocation, process redesign, and capacity planning skills enable her to enhance profit margins and achieve strategic goals. Lourdes brings expertise in Medicare and Medicaid reimbursement policies, ensuring effective and compliant financial practices.
6:00
Closing Comments
6:00 – 7:00
Networking drinks
Day Two: Thursday, 6 Feb, 2025
9:00 – 10:30
AI Symposium
AI for PI
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.
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.
A Discussion about Artificial Intelligence in Healthcare
AI for Governance
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.
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.
10:30 – 11:45
One-To-One Structured Networking
11:45 – 12:30
The Ongoing Threat of Telehealth Fraud
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.
12:30 – 1:15
Combating the Opioid Crisis Through Pharmacy Payment Integrity
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.
1:15 – 2:30
One-To-One Structured Networking
2:30 – 3:00
CA Medicaid Program Integrity
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.
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.
3:00 – 3:30
Test, Retest, Profit?
Discussion around the alarming rise of unnecessary lab tests, and the money wasted with this. Implementing robust payment integrity measures to combat such waste and fraud.
3:30 – 4:00
Tailoring Treatments and Curbing Costs with Precision Pharmacy
This session will explore how precision pharmacy can be used to optimize medication therapy for individual patients, leading to improved health outcomes while reducing overall healthcare costs.
4:00
Closing Remarks
End of Main Conference Party
Day Three: Friday, 7 Feb, 2025
9:30 – 10:30
Workshop 1
Applying AI and Data Analytics in Payment Integrity
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.
10:30 – 11:00
Networking
11:00 – 12:00
Workshop 2
Leveraging Interoperability and Data Exchange for Better Payment Integrity
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.
12:00 – 1:00
Goodbye Lunch
REGISTER YOUR INTEREST IN 2024
CONFERENCE PACKAGES
We accept the following cards through Stripe:
- Thursday, August 15, 2024 to Thursday, February 6, 2025Healthcare Payers & ProvidersCOMPLIMENTARY PASSAn organization that determine service prices, collect payments, and handle claimsA legal entity, or sub-set of a legal entity, which may contract for the provision of health care
- Thursday, August 15, 2024 to Thursday, February 6, 2025Vendors/Solution Providers$5,499Standard ratePayment Integrity VendorsRevenue Integrity VendorsConsultantsAnyone that provides a product or service to payers/providers
Preparing registration...
MEDIA KIT
For more information on webinars, roundtables, content marketing packages, interviews and marketing solutions opportunities, download the Media Kit.
If you have any questions, please contact Harry Ludbrook, Sales Director, [email protected].
HEADLINE PARTNER
AMS Intelligent Analytics
Website: http://www.amspredict.com/
Advanced Medical Strategies (AMS) is the premier provider of payment integrity, risk management, and business intelligence solutions to identify and address excessive claims, prevent and recoup overpayments, and effectively manage the risks associated with high-cost claimants and group health underwriting.
PLATINUM PARTNER
6 Degrees Health
Website: https://www.6degreeshealth.com/
6 Degrees Health is on a mission to reduce the cost of healthcare. We take a service-first approach to our Clean Claim Reviews to ensure accuracy in billing and fair payments. Using our extensive cost containment experience, clinical expertise, and next-generation, purpose-built software, we deliver remarkable savings for health plans. Our proprietary review process leverages CMS and other industry standard guidelines to evaluate every line item and identify billing errors and inconsistencies.
These pre-pay clinical reviews are completed by our team of highly trained and experienced registered nurses to ensure each billed line item is appropriate for reimbursement. This detailed review removes erroneous line items and verifies billing accuracy. Our comprehensive process manages claims during the review stage, as well as through payment and appeals resolution. Our white glove service on appeals allows us to maintain an uphold rate of 97 %, so your savings are secure.
Machinify
Website: https://www.machinify.com/
Machinify is transforming healthcare administration with AI. At the core of Machinify is an AI cloud platform that digests and unifies policies, guidelines, and data transforming healthcare administration. Machinify's platform and services power revolutionary applications that interoperate for seamless execution across the healthcare claims lifecycle:
- Machinify Audit: End-to-end system utilizing GenAI and large language models (LLMs) to perform automated coding validation of complex claims.
- Machinify Pay: Software that enforces coding and payment policies against claims and prices claims accurately.
GOLD PARTNERS
Carelon
Website: https://www.carelon.com/
The health of the healthcare system improves when spending is responsible and accurate. Today, platform technology and advanced analytics are paving the way to make that more efficient and more proactive than ever before. Backed by decades of experience, Carelon’s Payment Integrity solutions bring together breakthrough technology and human expertise to help speed your ability to drive cost savings and value for your stakeholders.
Healthcare Fraud Shield
Website: https://www.hcfraudshield.com/
Healthcare Fraud Shield specializes in fraud, waste, abuse, and error detection and payment integrity for healthcare payers nationally by efficiently stopping claims prior to payment using utilizing post-payment advanced analytics and artificial intelligence insights. We save health plans millions annually incremental to existing pre-payment processes using our unique and proven approach. HCFSPlatform™ offers the combination of targeted rules, artificial intelligence, shared analytics across multiple payers resulting in higher ROI (up to 20:1) compared to other vendors. HCFSPlatform™ software was developed by industry leading healthcare subject matter experts and is a component of over 60+ clients’ including 7 of the 10 largest commercial insurers in the US. Our client satisfaction rating is exceptional with a net promoter score of 84 and client retention rate over 95%. HCFSPlatform™ – is a fully integrated platform consisting of PreShield (prepayment), AIShield (AI), PostShield (post-payment), RxShield (pharmacy analytics), Shared Analytics, QueryShield (ad hoc query and reporting tool), CaseShield (case management), HCFSAudit, and medical record retrieval.
MedReview
Website: https://www.medreview.us/
Headquartered in the financial district of New York City and serving all U.S. states and territories, MedReview has been a leading provider of payment integrity, utilization management and quality surveillance services for more than 40 years. A physician-led organization with a passion for ensuring that health care claims fairly represent the care provided, MedReview provides timely independent hospital billing audits and clinical validation reviews on behalf of health plans, government agencies and Taft-Hartley organizations, saving millions of dollars for its clients each year.
Community Partner
4L Data Intelligence
Website: https://4ldata.com/
4L Data Intelligence™ uses the patented power of Integr8 AI™ to find, fight and prevent fraud, waste, and abuse fast with the revolutionary provider-centric FWA approach. Integr8 AI technology, coupled with our continuously credentialed provider database, detects FWA you can’t see with claim data-centric approaches, solving a challenge every payment integrity platform has today.
The 4L FWA Prevention™ solution rapidly detects and prevents FWA at five points across the claims management workflow including pre pre-payment, pre-payment and post-payment positions. At each point, Integr8 AI dynamically and continuously detects provider behaviors, relationships, and outlier status without the limitations of rules-based and claim data-centric solutions. In short, it enables you to see what providers are doing individually, in relationship with all other providers, and in relationship to all other claims on each-and-every claim submitted.
4L FWA Prevention pre-payment and post-payment detection and prevention results are delivered in four distinct categories. These are:
- Provider Integrity Edits
- Adaptive Claims Edits
- Provider Behavior Analysis
- Provider Schemes Analysis.
For fraud and SIU teams, Integr8 AI detects fraud and collusion schemes you can’t see now, or can’t see fast enough, with claim-centric approaches. Our suite of tools automates continuous near real-time SIU-in-a-box detection and documentation so you can Find, Fight and Prevent Fraud Fast™.
Ceris Health
Website: https://www.ceris.com/
CERIS has 30 years of prepay and post pay claim review and repricing experience with a 97% client retention rate. Our solutions are deep, consistent, and defensible reviews, which make CERIS the partner of choice for health plans, Medicare and Medicaid plans, and third-party administrators. CERIS’ longstanding review services and clinical expertise offer incremental value and are grounded in a sincere dedication to our valued partners. CERIS' mission is to continue to grow and deliver long term Payment Integrity services for our partners and to help them save.
DRG Claims Management
Website: https://www.drgclaims.com/
DRG Claims Management is an accuracy and integrity solutions firm, auditing claims for DRG and Clinical Validation, Cost Outliers, Readmissions, Short-Stay/OBS, and Skilled Nursing Facilities. Health Care Organizations partner with us to increase payment integrity savings and to improve claim payment performance. Our audits are completed on a Prepay, Post-payment or Hybrid basis.
Nokomis
Website: https://nokomishealth.com/
Nokomis was founded in 2013 by our current CEO Rich Henriksen to ensure Claim Accountability and make a difference in the healthcare system.
We are still privately owned and therefore only have to answer to our customers - that’s the way we like it.
Through 35 years in healthcare, Rich and his team compiled their deep and broad knowledge to build Nokomis and its proprietary technology, ClaimWise™. This unique technology finds patterns in claim data to identify claims for further review, regardless of dollar amount. Combined, ClaimWise™ and the Nokomis team intelligently select claims for review, finding errors even in claims that look fine at face value.
Performant
Website: https://www.performantcorp.com/home/default.aspx
Performant Healthcare Solutions is a leading independent provider of technology-enabled audit, recovery, and analytics services in the United States with a focus in the healthcare payment integrity industry. Performant works with healthcare payers through claims auditing and eligibility (coordination of benefits)-based services to identify improper payments. The Company’s commercial health plan clients include both national and regional payers that represent more than 100 million covered lives across all lines of business, including commercial, Medicare, and Medicaid coverages. Performant also supports numerous engagements with the Centers for Medicare & Medicaid Services, including multiple Recovery Audit Contractor contracts and the Medicare Secondary Payer Commercial Repayment Center contract, as well as a contract with the US Department of Health and Human Services, Office of the Inspector General for complex claim review nationwide. The Company also features a call center to serves clients with complex consumer engagement needs.
Powered by a proprietary analytic platform and workflow technology, Performant also provides professional services related to the recovery effort, including reporting capabilities, support services, customer care, and stakeholder training programs meant to mitigate future instances of improper payments. Founded in 1976, Performant is headquartered in Livermore, California. Visit www.performanthealthcare.com and follow us on Twitter: @PerformantCorp.
Shift Technology
Website: https://www.shift-technology.com/en-gb/
Please visit our website for more information.SILVER PARTNER
Apixio
Website: https://www.apixio.com/
Apixio, formerly ClaimLogiq, is the Connected Care Platform at the intersection of health plans and providers. Our AI technology and flexible services power risk adjustment, payment integrity, and care delivery programs using centralized patient health profiles, data-driven insights, and seamless workflows. By combining ClaimLogiq and the Apixio technology ecosystem, healthcare organizations can streamline operations, ensure accurate payment, and uncover critical patient insights—building a resilient foundation for success as the industry moves toward value-based reimbursement models. Visit apixio.com to learn more.
Exhibitor
Penstock Group
Website: https://www.penstockgroup.com/
Penstock is a service partner and SaaS builder for forward-thinking health plans and providers, empowering recovery, audit and regulatory teams to get accuracy right from the start—when it matters most. Our mission is to create lasting systemic change that removes wasted spend from our healthcare system, returning dollars to payers, lowering the cost of care and improving access for all.
Penstock is powered by industry veterans who are some of the most sought-after payment integrity and regulatory experts in the industry. Our business model is rooted in transparency and the drive to reinstate true integrity in payment integrity—even if it defies traditional business sense.
Our audit workflow SaaS platform, ClearBridge gives health plans the tools and insights they need to identify overpayments, correct them and implement their own edits with ease, ensuring correct payments and mitigating future discrepancies.
When you partner with Penstock, you reclaim time and control with an end-to-end partnership that beautifully and seamlessly connects human and machine intelligence—to prevent recurring issues at the source.
PARTNER WITH US
Based on your objectives, we can create bespoke packages designed specifically for you – from presenting your expertise on the main stage, to hosting a private dinner. You can partner with us showcase your brand and make valuable new connections. Opportunities predominantly lie in 3 main categories: Thought Leadership, Branding & Networking.
To discuss your objectives and partnership opportunities please contact Harry Ludbrook, Sales Director [email protected]
Interested in a media partnership?
We'd love to hear from you and how we can support one another to connect with the industry. Contact Jodie Purser, Marketing Manager, [email protected]
PARTNER WITH US
Based on your objectives, we can create bespoke packages designed specifically for you. Opportunities predominantly lie in 3 main categories: Thought Leadership, Branding, and Networking.
Interested in a media partnership?
We'd love to hear from you and how we can support one another to connect with the industry. Contact [email protected]
Delivering scalable and flexible solutions which ensure accuracy and integrity of claims
Join us at the 7th Annual Healthcare Payment & Revenue Integrity Congress returning in Nashville!
Whether you’re looking for vendors with proven ROI or insourcing strategies from health plan leaders, this event has it all. Explore AI-driven solutions for improving data analytics, reducing FWA, and enhancing claims accuracy. Network with peers and collaborate with providers to drive efficiency and financial success for your plan!
Venue
MILLENNIUM MAXWELL HOUSE HOTEL 2025 Rosa L Parks Blvd, Nashville, TN 37228
We're excited to welcome you face-to-face in Nashville at Millenium Maxwell House Hotel for the Healthcare Payment & Revenue Integrity Summit!
If you're looking for accomodation, you can book at a discount here.
About Kisaco Research
Kisaco Research produces, designs and hosts B2B industry conferences, exhibitions and communities – focused on a specialized selection of topic areas.
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