TAKEAWAYS INCLUDE:
In this agenda you will find sessions on topics including:
- Strengthening payer-provider relationships and outlining strategies for reducing provider abrasion
- Optimizing workflows and encouraging cross functional collaboration between claims, audit, FWA, SIU, and PI teams
- Leveraging advanced tech, such as GenerativeAI, to increase efficiencies across the healthcare value chain
- Preventing revenue leakage by deploying intelligent automation and building proactive denial management systems
- Discussing best practices for building payment integrity programs from the ground up at smaller health plans
To learn more about the CEU accredited sessions, click on the session title
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Wednesday, 11 Sep, 2024
08:00am
10:00am
Session Overview
- With rising medical utilization, diminished prior auth, and greater inflationary pressures, health plans now more than ever must adopt innovation to prevent spend on fraud, waste and abuse (FWA). FWA reduction offers a huge opportunity to improve spend and member outcomes – by reducing unnecessary spend and aligning providers with best practices to avoid waste and harm. With new advances in FWA detection, plans can now improve their ability to reduce payment on FWA claims with tools that analyze patient data and provider patterns to precisely identify the services that might be wasteful or abusive.
During this case study, ATRIO Health Plans and Health at Scale will discuss the impact seen from implementing smart, context-aware FWA flagging into pre-adjudication along with a targeted provider education campaign and how the team was able to successfully drive down medical spend by 1.8% in the first year.
Learning Objectives/Key Takeaways of the Session
- Learn how ATRIO Health Plans crafted an innovative new FWA detection program and the factors that led to their substantial spend improvement
- See how new advances in FWA detection improve upon traditional systems by considering real-time context about individual patient history, provider patterns, and medical guidelines to determine if a service is appropriate
- Learn how FWA flagging in pre-adjudication can be supplemented with a targeted provider education program to align provider practices with best standards of care
Jennifer Callahan
COO
ATRIO Health Plans
Jen Callahan is the President and Chief Operating Officer of ATRIO Health Plans. For over 20 years, Jen has established herself as a trusted thought leader who helped shape the managed care industry with her innovative ideas and expertise. Jen has dedicated her career almost exclusively to Medicare Advantage and Medicare Supplement programs.
Prior to joining ATRIO, she co-founded a field management organization, Keen Insurance Services, Inc. to create a provider-centric Medicare focused sales and distribution organization from the ground up. Prior to that, she held the position of Vice President, Medicare Product at Aetna, a CVS Health company where she oversaw the product development and implementation of Aetna’s entire Medicare portfolio supporting record breaking growth for the Medicare organization. Throughout her career, Jen has also held various leadership positions at Healthfirst and Elevance.
Jen received her Bachelor of Science degree from Fordham University and MBA from North Carolina State University. Jen currently resides in Waxhaw, a suburb of Charlotte, North Carolina with her husband, their three kids, tuxedo cat, Vivi and golden retriever puppy, Steve.
Zeeshan Syed
Chief Executive Officer
Health at Scale
Zeeshan serves as Health at Scale’s CEO and was a Clinical Associate Professor at Stanford Medicine and an Associate Professor with Tenure in Computer Science at the University of Michigan. He was previously part of the early stage team that launched Google[X] Life Sciences (now Verily). Zeeshan is a recipient of multiple awards including an NSF CAREER award and holds a PhD from MIT EECS and Harvard Medical School in Computer Science and Biomedical Engineering, and MEng and SB degrees in EECS from MIT.
Health at Scale, Corp.
Website: https://www.healthatscale.com/
Health at Scale is advancing the next-generation of fraud, waste and abuse detection through real-time context-aware intelligence that allows health plans and third-party administrators to detect and act on inappropriate payments across pre-adjudication and post-pay. Founded by artificial intelligence and clinical faculty from MIT, Harvard, Stanford and U-Michigan, the company offers software solutions and fully-managed technology-enabled services to contain medical costs and reduce administrative burden. Health at Scale’s customers include some of the largest payers and TPAs in the U.S.; with the company’s breakthrough Precision FWA Detection™ technology consistently demonstrating 1-2% incremental reduction in total medical spend in large prospective deployments for Medicare Advantage and Commercially-Insured populations.
For more information please visit healthatscale.com.
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.
12:15pm
CEU Eligibility: COC, CPC, CPC-P, CPB, CPCO, CPMA, CPPM
To address the increasingly high costs and large product variation of implant devices it is important to develop an implant payment integrity program and policy. This promotes transparency between payer and provider, in addition to a more predictable implant and device spend, potentially lowering medical spend and healthcare costs. This can be achieved by utilizing evidence-based clinical guidelines, industry standard reimbursement methodologies and contracting. In addition, develop reporting and a claims review process to detect safety and quality gaps in implant usage to recoup or stop potential overpayments.
Learning Objectives:
- Outpatient Outlier Payments for Claims
- Credits for Replaced Medical Devices
- Best practices for payer implant policy creation
- Trends in inappropriate implant usage and billing
Stephanie Sjogren
Director, Coding and Provider Reimbursement
EmblemHealth/Connecticare
Stephanie Sjogren is a director of coding and provider reimbursement, working with payment integrity to ensure proper claims adjudication and to prevent fraud, waste, and abuse. Prior to joining ConnectiCare/EmblemHealth, she performed provider audits and education at a women’s healthcare group. Sjogren has also worked with physicians and staff to integrate and use electronic health record systems effectively and to stay in compliance with the Centers for Medicare & Medicaid Services’ rules and regulations. Her areas of specialty are payment integrity, auditing, and clinical documentation improvement.
2:45pm
Description: CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM
Over the last few years, there have been many cases of hospitals receiving inappropriate reimbursement for medical procedures. This session will focus on the procedures associated with these cases, including diagnostic and therapeutic procedures for access sites of dialysis patients, peripheral vascular patients and a variety of surgical procedures. We will explore these cases and discuss the characteristics and scenarios that lead to inappropriate reimbursement.
Learning Objectives:
Through the case study approach, examine specific types of hospital procedures that have been associated with inappropriate reimbursement
Explore methods for preventing, detecting and correcting errors leading to inappropriate reimbursement for these procedures.
CJ Wolf
Professor and Asst. Program Director
Brigham Young University-Idaho
3:15pm
5:15pm
CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM
Over the last few years there have been many cases of hospitals receiving inappropriate reimbursement for medical procedures. This session will focus on the procedures associated with these cases, including diagnostic and therapeutic procedures for access sites of dialysis patients, peripheral vascular patients and a variety of surgical procedures. We will explore these cases and discuss the characteristics and scenarios that lead to inappropriate reimbursement.
Learning Objectives:
-Through the case study approach, examine specific types of hospital procedures that have been associated with inappropriate reimbursement
-Explore methods for preventing, detecting and correcting errors leading to inappropriate reimbursement for these procedures.
CJ Wolf
Professor and Asst. Program Director
Brigham Young University-Idaho
5:30pm
- Speed up reimbursement and streamline day-to-day operations through efficient data exchange to enable prior authorization, claim status monitoring and identification of care gaps.
Darren Wethers
Chief Medical Officer
ATRIO Health Plans
Darren Wethers is a board-certified internal medicine physician and certified physician executive.
He graduated from Morehouse College, Northwestern University Medical School and completed internal medicine training at Emory University School of Medicine before establishing an internal medicine practice in the St. Louis, Missouri area, becoming a “Top Doctor” Honorée several years running. Dr. Wethers was the medical staff president at SSM St. Mary’s Health Center in 2006-07 and chaired the facility’s Credentials committee 2007-11.
In 2011, Dr. Wethers began a career in administrative medicine, servings as a medical director with Coventry Health Care and Aetna, vice president of clinical operations at Blue Cross Blue Shield of Arizona and is now at Atrio Health Plans, where he serves as chief medical officer.
Dr. Wethers is a member of the American Association for Physician Leadership, Fellow of the American College of Physicians, member of Alpha Phi Alpha and Sigma Pi Phi fraternities; he is a board member and immediate past chairman for Gamma Mu Educational Services (GMES) and is a board member of Northwestern University Medical School Alumni Association, for which he serves as president-elect and co-chair of the Inclusion and Allyship committee.
Brittany Biggett-Heeren
Compliance Analyst
Orlando Health
7:30pm
Thursday, 12 Sep, 2024
09:30am
Presentation on AI use cases and success stories for your implementation
Break out groups to discuss health plans' strategies and feedback to the wider group
Michael Devine
Director Special Investigations Unit
L.A Care
Stephanie Sjogren
Director, Coding and Provider Reimbursement
EmblemHealth/Connecticare
Stephanie Sjogren is a director of coding and provider reimbursement, working with payment integrity to ensure proper claims adjudication and to prevent fraud, waste, and abuse. Prior to joining ConnectiCare/EmblemHealth, she performed provider audits and education at a women’s healthcare group. Sjogren has also worked with physicians and staff to integrate and use electronic health record systems effectively and to stay in compliance with the Centers for Medicare & Medicaid Services’ rules and regulations. Her areas of specialty are payment integrity, auditing, and clinical documentation improvement.
Josh Miller
Director, Payment Integrity
Prominence
2:30pm
CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM
In the ever-evolving landscape of healthcare, balancing cost containment with maintaining strong provider relationships is a critical challenge. This session will explore effective strategies to control costs while fostering positive, collaborative relationships with providers. Attendees will gain insights into practical approaches and best practices that align financial objectives with the goal of delivering high-quality patient care.
Learning Objectives:
- Collaborative Approaches to Payment Integrity
- Efficient Billing and Coding Practices
- Provider Education and Training
- Monitoring and Continuous Improvement
Jonique Dietzen
Payment Integrity Director
CareOregon
With over 18 years of experience in healthcare billing and finance, I am a certified professional coder dedicated to ensuring accurate claims and proper reimbursement for providers. Having worked extensively on the provider side in finance and revenue cycle, I bring wealth of knowledge to the table, particularly in processing and payment integrity.
Throughout my career, I have gained a comprehensive understanding of billing challenges from both perspectives. This unique insight drives my commitment to improving billing practices and advocating for provider education. I continue to leverage my expertise to enhance billing processes and support providers in navigating the complexities of healthcare finance.
Eric Carter-Nadeau
Operations Manager, Provider Network
CareOregon
3:00pm
The session will cover two drug categories and medications commonly used and current trends of fraud, waste and abuse. The four medications include GLP-1 (Ozempic/Mounjaro) and Antivirals combinations (Descovy & Biktarvy). Each drug will cover its directed use by manufacturers and common side effects, this will segue into issues of patient harm being inappropriately prescribed and its financial impact on health plans. Data analytic tactics using patient historical clinical indications to identify potential FWA providers/members and approaches to address outliers. The aftermath of inappropriately prescribing causing pharmacy inventory shortages, diversion, misbranding and counterfeit production by fraudsters for profit.
Learning Objectives:
1) Identifying counterfeit medications mentioned in presentation.
2) Implementation of provider education, recoveries and cost-saving best practices
Eric Renteria
Senior Fraud Investigator
L.A. Care Health Plan