CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM
Strategies for identifying savings and reducing costs in pharmacy operations through:
- Formulary design and management
- Inventory control and standardization
- Utilization management
- Provider engagement
Helen Liu, Pharm.D.
VP of Pharmacy Operations
ATRIO Health Plans
Dr. Liu is the Vice President of Pharmacy Operations for the ATRIO Health Plans, where she manages and oversees all Part D-related operations. Dr Liu has an extensive background in clinical pharmacy, medication safety, managed care, and data outcome analysis. Before this role, she developed and implemented the inpatient Drug Use Management program at Kaiser Permanente.
- Round Table 1: AI V Human: Dealing with Complex Claims
Discussion around where artificial intelligence has beneficial uses and where human expertise is necessary to achieve results- with a specific focus on complex claim review
- Round Table 2: Create Contracts that Work for You
Identifying how contract language can be altered to ensure you limit unnecessary payments and save money “indirectly”
- Round Table 3: Meeting Requirements for Interoperability
Meeting interoperability requirements and ensuring EHR exchange is efficient for appropriate patient care and timely coverage decisions
CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM
- Establish governance strategies through varying development stages of payment integrity functions to maximize operational expenditure
Josh Miller
Director, Payment Integrity
Prominence
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.