Medical Cost Containment
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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
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.
Machinify
Website: https://www.machinify.com/
Machinify is the trusted AI partner for healthcare admin, providing software and services that enable health plans to accurately and efficiently pay claims, leading to a reduction in provider abrasion. With safe, transparent AI and deep clinical expertise, Machinify brings a unique blend of speed, accuracy, and intelligence health plans need to make healthcare admin more efficient.
The company serves partners of all sizes with its two products:
● Machinify Audit - Medical AI system identifying erroneous claims and performing record review.
● Machinify Pay - AI models and SME expertise to process claims at wire speed, ensuring accurate coding and pricing.
- Gain insights into the current state of the RCM industry and understand the key challenges healthcare organizations face.
- Identify strategic priorities for enhancing financial performance and optimizing the revenue cycle.
- Explore the impact of adopting cutting-edge technologies and tools to streamline revenue cycle management processes, reduce costs, and improve overall profitability.
Revenue Cycle Management
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/
Lisa Meredith
AVP, Revenue Cycle Management
LifePoint Health
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
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.
Learn how to identify and overcome clinical and technical denial triggers, potentially saving your organization millions in lost revenue.
- Walk away with actionable, data-driven techniques to analyze your denial trends, close process gaps and improve first-pass resolution rates.
Revenue Cycle Management
Lisa Meredith
AVP, Revenue Cycle Management
LifePoint Health
Howard Kung
Senior Director, Revenue Cycle
Mayo Clinic
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
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.
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
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.
- Learn proven tactics and strategies that the panelists have implemented within their organization to handle denials effectively and efficiently as they arise.
- Listen to our expert panel as they provide practical insights on building a robust denials management program.
- Discover the role technology plays in tracking, analyzing, and optimizing denial management workflows in our panelist's organizations.
Revenue Cycle Management
Paul LePage
Executive Director, Revenue Cycle Operations
Banner Health
Betye Ochoa
Director, Revenue Cycle Redesign
NorthShore University HealthSystem
Ebrahim Barkoudah
System Chief & Regional Chief Medical & Quality Officer
Baystate Health
Brennan John
Director, Revenue Cycle
Intermountain Health
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
Healthcare Fraud Shield
Website: https://www.hcfraudshield.com/
Healthcare Fraud Shield specializes in fraud, waste, abuse, & 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, and shared analytics across multiple payers resulting in higher ROI (up to 20:1) compared to other vendors. HCFSPlatform™ software platform 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 94 and
client retention rate over 95%.
HCFSPlatform™ is a fully integrated platform consisting of PreShield (prepayment analytics & claim review logic), PostShield (post-payment analytics), AIShield (AI-driven analytic insights), RxShield (pharmacy and pharmaceutical specific analytics), Shared Analytics, CaseShield (SIU/PI case management), QueryShield (ad hoc query and reporting tool), HCFSServices (data mining, investigative, and record reviews), and HCFSAudit (Medical Record Review & SVRS).
12:00pm
Payment Integrity
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
Payment Integrity
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.
- Discover the four key capacity drivers that enhance patient access.
- Learn strategies to maximize capacity and access across clinics, groups, and organizations.
- Understand the metrics for measuring capacity and access and explore their interconnections.
Revenue Cycle Management
Paul Schmitz
Executive Director, Patient Access
AdventHealth
12:30pm
Payment Integrity
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.
Payment Integrity
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.
Listen to quick tips on expediting front-end revenue cycle processes such as registration, insurance verification and pre-authorisation.
Deep dive into specific metrics on how an integrated financial clearance process can help your revenue cycle.
- Learn the challenges and benefits of technology adoption in early patient access.
Revenue Cycle Management
Ismet Sharich
Patient Access Director
Riverside Healthcare
02:30pm
- 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
Payment Integrity
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.
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.
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.
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.
- Explore the tenets of financial sustainability for healthcare organizations.
- Gain insight into hospital governance.
- Engage in a tactical discussion on collaboration between payors and healthcare organizations.
- Envision the future of a successful healthcare ecosystem - Clinical and Clinician Integration: A Thought Provocation.
Revenue Cycle Management
Dr Deepak Goyal, MD, MBBS, MBA, CPE, CHCQM, CMRP, CMPC
Executive Medical Director Revenue Cycle and Supply Chain
Monument Health
03:00pm
- Learn to solve one of the most costly RCM Challenges - An open discussion regarding practical tools and insights to minimize costly errors and boost revenue.
- Discover technology enablers - How to determine if the value is attainable when choosing technology.
- Learn how to leverage all resources - The solution must include both your team and your technology.
Stacy Calvaruso
Vice President of Sales and Client Delivery
ASP-RCM Solutions
04:45pm
- Expand your perspective by exploring LOVE as a transformative business strategy.
- Discover how loving leadership fosters a culture of engaged and motivated employees.
- Reflect on strategies for normalizing love as an integral part of business practices.
Revenue Cycle Management
Cynthia Johnson
(former) Senior Director, Referral & Claims Administration
Kaiser Permanente
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
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.
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.
- Discover a proven approach to cultivating top performers as a foundation for sustained success. We will focus on the 3 Cs—compassion, consistency, and coachability—key traits for leaders at every level.
- Learn how setting clear guardrails for leadership while promoting autonomy can drive high-performing, cohesive teams.
- Explore how adopting a servant-supportive leadership style led to measurable results, including a 22.3% increase in team engagement, a 117% reduction in turnover, and an improved budgeted fill rate from 93.2% to 98.5%.
Revenue Cycle Management
Willie Brown
VP, Revenue Cycle
Sentara Healthcare
05:45pm
- This presentation will provide a detailed Case Study review of Trinity Health’s Lean Daily Management Training Effectiveness Dashboard and the methodology used to measure Revenue Cycle knowledge transfer and proficiency.
- These tools and strategies are vendor agnostic and, in this example, will be applied to seventeen (17) different Health Information Systems (HIS) using the Kirkpatrick Model of Assessment and our experience with over 8,000 trainees.
- Content will provide a “deep dive” into what is possible in the assessment of Revenue Cycle training and, in addition, give a Journey Map for organizations to start where they are to begin evaluating their Revenue Cycle training effectiveness.
Revenue Cycle Management
Edward Thomas
Director, Enterprise Revenue Cycle Training & Deployment
Trinity Health (HQ Michigan)
Thursday, 6 Feb, 2025
09:00am
AI for PI (Christopher Draven, Crystal Son)
Session in Partnership with Alivia Analytics
AI for Governance (Crystal Son, Simi Binning)
Payment Integrity
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.
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.
Alivia Analytics
Website: https://www.aliviaanalytics.com/
Your most expansive Payment Integrity and FWA partner for medical, pharmacy, vision, and dental claims. This features our powerful, configurable Alivia 360™ Platform that provides pre- and post-payment flexibility and considerable cost savings across the healthcare claims management process. It seamlessly transitions between FWA detection and Payment Integrity solutions including clinical and non-clinical audit scenarios, first- and second-pass claims editing, and COB/TPL. Alivia 360™ not only ensures comprehensive financial oversight but full adaptability to operational needs. Alivia integrates AI as an assistant, not a replacement, prioritizing ethical use, human oversight, and compliance with industry standards. Our solutions are offered as SaaS or tech-enabled services that build strong cases against inappropriate billing practices, identify new recoveries missed by legacy vendors, deliver actionable analytics, and offer automated corrections. Alivia enables healthcare payers to streamline vendor management, improving control and strategic decision-making. Schedule a discovery meeting and demo.
09:30am
- Gain a concise overview of the 5 OIG healthcare risk areas, including the False Claims Act, Anti-Kickback Statute, Civil and Monetary Penalties, Exclusions, and the Stark Law.
- Discover the areas commonly denied and at risk of violating the False Claims Act, including medical necessity of admissions and services, unbundling and improper coding and modifier assignment, double billing, billing for services not provided, upcoding, and billing non-covered services as provided.
- Walk away with resources available to identify what the OIG is targeting and internal resources that facilities can utilize to identify and mitigate hospital-specific risks.
- Learn about the factors to consider when determining the need to involve legal counsel.
Revenue Cycle Management
Jill Sell-Kruse
Director, Compliance Risk & Oversight Ethics & Compliance
ScionHealth
10:00am
- Stay ahead of the latest OIG and CMS Coding Compliance regulations and learn how to proactively implement these updates in your departments or practices.
- Review key changes to the OIG Compliance guide and understand their potential impact on your operations.
- Discover proactive strategies to address compliance issues and stay informed on the most recent updates in the compliance landscape.
Revenue Cycle Management
Sandy Giangreco Brown
VP, Revenue Integrity & Education
Spire Orthopedic Partners
11:45am
• Identify risk areas in chargemaster (CDM) pricing that are often overlooked.
• Describe ways to rationalize and defend pricing.
• Effectuate processes to stay current with price transparency regulations.
Revenue Cycle Management
Sandy Giangreco Brown
VP, Revenue Integrity & Education
Spire Orthopedic Partners
12:15pm
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.
Payment Integrity
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.
Revenue Cycle Management
Frank Shipp
Executive Director
Johns Hopkins Medicine
Frank E. Shipp currently serves as Executive Director of the Johns Hopkins Clinical Alliance, the clinically integrated network of Johns Hopkins Medicine. The network includes over 3,000 providers, consisting of both employed and independent practices.
Frank transitioned to value-based care after 25 years of hospital-based operations experience in both community and academic health systems. During the past nine years, Frank has held executive positions in a Payor-Provider Organization in NYC and has built a highly successful CIN over a five-year period in Northern New Jersey. Frank speaks regular at national healthcare conferences regarding value-based care strategies and tactics.
Frank completed his MBA at Fairleigh Dickinson University, is a certified Fellow of the American College of Healthcare Executives and a trained Black Belt in Lean Six Sigma from Villanova University.
12:45pm
Explore insights and strategies needed to navigate contract negotiations with confidence and expertise, ensuring you secure the best terms for your organization.
Recognize resources for the rules governing various types of health plans and contracting entities.
Understand different reimbursement models, discuss techniques for preparing for
and conducting successful contract negotiations, and highlight common
challenges and how to overcome them.
Revenue Cycle Management
Richelle Marting
Director, Managed Care Contracting
North Kansas City Hospital, Meritas Health Corporation
02:45pm
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
Explore strategies for fostering stronger partnerships and enhancing cooperation between payers and providers to achieve mutual goals.
Discover how payers and providers can work together more effectively in key areas such as risk adjustment, utilization management, data sharing, and value-based care.
Learn how successful collaboration can lead to better patient outcomes, more accurate reimbursements, and improved financial performance for both payers and providers.
Revenue Cycle Management
Cynthia Johnson
(former) Senior Director, Referral & Claims Administration
Kaiser Permanente
Catherine Pesek Bird
Physician Advisor
Lakeland Regional Health-Florida
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.
03:15pm
Learn practical strategies to help your organization navigate the intricacies of working with numerous payers, each with its own rules, requirements, and reimbursement models.
Our expert speaker will share insights on keeping up with compliance, optimizing workflows, leveraging technology for more efficient payer management, and building stronger relationships with payers.
Revenue Cycle Management
Garland Goins Jr
VP, Revenue Cycle Management
Avance Care
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.
03:45pm
Discover practical communication strategies to keep patients informed, engaged, and satisfied beyond their visit to the hospital.
- Explore the latest cutting-edge technology, such as automated messaging, AI-driven communication platforms, and personalized outreach strategies.
Revenue Cycle Management
Andrew Zurick
Medical Director Cardiac CT & MRI, Staff Cardiologist
Ascension, St Thomas Heart
Michelle Myers
Director, Patient Financial Services
Boulder Care
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
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.
Friday, 7 Feb, 2025
09:30am
- Discuss assessing and selecting the right technologies (e.g., EHRs, automation tools, AI, and analytics platforms) that align with an organization’s RCM needs and overall goals, considering factors like cost, scalability, and ease of integration.
- Explore the technical challenges of integrating diverse technologies into existing RCM workflows, including data interoperability and system compatibility.
- Address the human element of technology adoption, focusing on how to manage change within the organization, train staff effectively, and foster a culture of innovation to ensure successful implementation.
- Discuss how to measure new technologies and return on investment (ROI), including key metrics like reduced Days in AR, increased collection rates, improved patient satisfaction, and cost savings.
Revenue Cycle Management
Brennan John
Director, Revenue Cycle
Intermountain Health
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.
Payment Integrity
4L Data Intelligence
Website: https://4ldata.com/
4L Data Intelligence™ is leading the way in a new era of healthcare program and payment integrity using the patented power of Integr8 AI Risk Detection™ technology to find, fight and prevent FWA in near real-time. Integr8 AI™, coupled with our continuously credentialed provider database, creates a revolutionary provider-centric capability to dynamically detect FWA you cannot see with stacks of traditional claims data-centric editing and analytics solutions.
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, patented Integr8 AI technology dynamically and continuously detects provider behaviors, relationships and outliers 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 continuously delivered in four complementary modules. These are:
- Provider Integrity Edits
- Adaptive Claims Edits
- Billing Behaviors Analysis
- Provider Schemes Analysis.
For SIU teams, the new 4L SIU Hub™ packages the expanded range of Integr8 AI powered FWA detection behaviors and schemes into easy to use views with comprehensive investigation and lead management tools. This new capability increases FWA detection, reduces complexity and increases speed-to-decision on lead triage and investigation. All so you can Find, Fight and Prevent FWA Fast™.
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
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/