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.
- Gain insights into the current state of the RCM industry and understand the key challenges healthcare organisations face.
- Identify strategic priorities essential for enhancing financial performance and optimising 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
09:00am
- Learn how to identify and overcome clinical and technical denial triggers, potentially saving your organization millions in lost revenue.
- Gain insider knowledge from our expert panellists on the top reasons for claim denials and disocover how to tackle common pitfalls in insurance verification, pre-authorisations, documentation, and coding.
- 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.
Learn tactics and proven strategies 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, including strategies for categorising and prioritising denials based on financial impact and resolution probability.
- Discover best practices for streamlining the appeals process and leveraging data analytics to track, analyse, and optimise your denial management workflows, empowering you to reduce losses and accelerate reimbursement times.
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
- Explore how AI/ML can streamline denial management processes and drive financial performance.
- Overcome the challenges of deploying AI/ML by learning actionable steps to help your organization achieve seamless integration and maximise the impact of these tools.
- Address the elephant in the room. Confront the critical cost vs. outcome debate with an in-depth analysis of key metrics.
Revenue Cycle Management
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.
12:30pm
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.
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.
Discuss how to ensure accuracy during patient registration to avoid claim denials and delayed reimbursements.
Explore the role of automation tools (e.g., robotic process automation, AI-driven analytics) in improving data capture, reducing manual errors, and providing actionable insights to optimize patient access workflows.
Revenue Cycle Management
03:00pm
- 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)
04:45pm
Payment Integrity
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.
- This presentation will showcase a proven approach to growing top performers, emphasizing its importance as a key component to sustainable success. The methodology highlights how building cohesive teams and identifying leadership talent are anchored in what Mr Brown calls the 3 Cs—compassion, consistency, and coachability—non-negotiable traits for leaders at all levels.
- The content will dive into how setting clear guardrails for leaders while allowing autonomy fosters high-performing teams.
- By adopting a servant-supportive leadership style, Mr Brown and his team achieved measurable results, including increasing their budgeted fill rate from 93.2% to 98.5%, reducing turnover by 117%, and boosting the team member engagement index by 22.3% over 18 months. These outcomes were realized in patient access teams, a sector known for talent retention challenges.
Revenue Cycle Management
Willie Brown
VP, Revenue Cycle
Sentara Healthcare
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.
- This session will discuss the concept of Love in business and how it can be a specific business strategy to drive performance, positive business outcomes, and employee retention.
- Real-life stories, as well as quantifiable studies, will be shared to demonstrate the tangible value of love in business.
- Finally, a 4-dimensional tool will be presented to encourage participants to explore HOW they can bring love into business practice.
Revenue Cycle Management
Cynthia Johnson
(fomer) Senior Director, Referral & Claims Administration
Kaiser Permanente
Thursday, 6 Feb, 2025
08:30am
- Explore how accurate coding practices can reduce claim denials, enhance reimbursement rates, and streamline revenue cycle processes.
- Discover actionable ways C-level executives can empower coding professionals to drive better financial outcomes.
Revenue Cycle Management
Howard Kung
Senior Director, Revenue Cycle
Mayo Clinic
09:00am
09:30am
- This session will briefly overview 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. This includes 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
12:15pm
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
12:45pm
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
(fomer) Senior Director, Referral & Claims Administration
Kaiser Permanente
Catherine Pesek Bird
Physician Advisor
Lakeland Regional Health-Florida
2:30pm
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
03:00pm
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.
03:30pm
- Explore the latest cutting-edge technology, such as automated messaging, AI-driven communication platforms, and personalised outreach strategies, to keep patients informed, engaged, and satisfied beyond their visit to the hospital.
Revenue Cycle Management
Andrew Zurick
Medical Director Cardiac CT & MRI, Staff Cardiologist
Ascension, St Thomas Heart
04:00pm
- Explore Banner Health’s practical approaches to engaging patients proactively and reducing financial avoidance behaviours that lead to delayed or missed payments.
- Our expert speaker will share insights on understanding the root causes of financial avoidance, leveraging technology for financial engagement, building trust and reducing patient anxiety related to financial responsibilities.
Revenue Cycle Management
Becky J. Peters
Executive Director of Patient Access Services
Banner Health
Friday, 7 Feb, 2025
09:30am
- This is your opportunity to dive deep into data challenges in your RCM.
- Explore methods to improve data quality at the point of entry.
Address the difficulties in integrating data across disparate systems such as EHRs, billing platforms, and payer systems, and the role of standardization in improving data flow and communication.
Explore the use of robotic process automation (RPA) and AI for automating routine data tasks, reducing errors, and enhancing data processing speed across the revenue cycle.
Review how to ensure compliance with healthcare regulations (HIPAA, GDPR, etc.) when handling patient data and the importance of protecting sensitive information against breaches and unauthorized access.
Revenue Cycle Management
11:00am
This is your opportunity to wrap your head around adopting and integrating diverse technologies.
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' 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