- Implementing a streamlined claims process to prevent missing information and incorrect coding, and
tracking patterns claim denials to mitigate future issues
- Highlighting causal factors such as front-end errors related to benefit information, coverage details, and
missing or invalid claims data
- Discussing the value of automated denial management systems as a means to reduce administrative
burden
Revenue Integrity
- How does Claim Audit fit into the overall savings goals from PI?
- Archaeology amongst savings drivers? High $ treasures?
- Claim Audit Digs & Research – driving process improvement, not just savings.
- Do underpayments matter?
- How to keep finding treasure:
- Partnering with other departments as a true “Partner” not an “Auditor.”
- It will all be in a museum (creating reference materials).
Payment Integrity
Tom Martin
AVP, Payment Integrity
Molina Healthcare
- Using an AI-first approach to enhance transparency and accuracy throughout the payment continuum
Payment Integrity
Mike Spellman
Senior Director, Consulting & Solution Design
Lyric
Lyric
Website: www.lyric.ai
Lyric is the trusted leader in healthcare decision intelligence. Built on more than 35 years of proven results, Lyric combines responsible AI with clinical, payment, regulatory, and policy expertise to deliver transparent, auditable insights in milliseconds across real-time claims workflows. Lyric augments human decision-making so health plans can make faster, more accurate payments while maintaining full control. Today, Lyric supports 200 million lives, with nine of the top 10 U.S. health plans relying on its platform to reduce waste, improve efficiency, and support accurate payments. To learn more, visit lyric.ai.
- Understanding the importance of CDI in Modern Healthcare.
- The link between CDI and Denial Management.
- Collaborative Strategies.
- Technical Solutions & Data Analytics.
- My Succes Story & Key Takeaways.
Revenue Integrity
Vladimir-Ducarmel Joseph
CDI Program Manager
Beth Israel Lahey Health Hospital & Medical Center
Vladimir-Ducarmel Joseph is one of the Clinical Documentation Integrity Program Directors at Beth Israel Lahey Health, where he spearheads a dedicated team of CDI professional experts to optimize clinical documentation best practices. With almost a decade in CDI leadership across diverse healthcare environments, Vladimir-Ducarmel holds a Master of Health Administration from George Washington University and his expertise encompasses physician leadership, team dynamics, CDI provider education, and program management. A fervent advocate for healthcare excellence, Vladimir-Ducarmel is adept at bridging the gap between clinical and administrative roles. He is proficient in various healthcare-oriented analytical and business tools, leveraging them to drive impactful CDI outcomes.
- Developing a Payment Integrity Program from the ground up for a brand new Medicare Advantage Health Plan
- Covering both the opportunities and the challenges of building and effectively managing PI programs that prevent, avoid, or recover billing errors, payment errors and other party liability errors
- Listing of suggestions/ advice from our success, and lessons learned
Payment Integrity
Monique Pierce
Head of Payment Solution Strategy
Cohere Health
Monique started her Payment Integrity career in COB at Oxford HealthPlans. After the merger with UnitedHealthcare, she led multiple teams and was responsible for creating innovative programs. Monique joined SCIO Health Analytics in 2014 and was responsible for system and process improvements before being promoted to VP of client engagement and business optimization In 2020, Monique joined start-up Devoted Health and created a full suite of programs from the ground up. Based on a passion for metrics and measuring performance, she centralized and standardized all programs reducing implementation time and maximizing savings. Today, Monique is driving opportunities to improve claim payment by designing and developing new prior auth and claim reconciliation products at Cohere Health.
- Strengthening payer-provider relationships through improved communication around claims adjudication, providing transparency into denials, accelerating payments, automating data exchange, and reassessing denial
reversals
Payment Integrity
Revenue Integrity
Join us for an engaging panel discussion featuring a lineup of industry experts as they tackle pressing questions at the intersection of health plan payment integrity and hospital revenue integrity. Discover the challenges and solutions in achieving payment accuracy and delve into the potential of collaboration and data sharing between health plans and hospitals. Explore critical topics, including the impact of payment inaccuracies on financial health, the role of technology and automation, navigating regulatory complexities. Gain insights into measuring success and envision the future of payment integrity in healthcare. Don't miss this opportunity to be part of a dynamic conversation that could reshape the healthcare landscape. Join us as we challenge conventional wisdom and seek innovative solutions to drive payment accuracy forward.
Payment Integrity
Revenue Integrity
Ritesh Ramesh
Chief Executive Officer
MDAudit
Conor McCauley
Director, Payment Integrity Clinical Capabilites
Highmark Health
My name is Conor McCauley. I am the Director of Payment Integrity Clinical Capabilities at Highmark. Being a Critical Care nurse, it is easy to see there are issues surrounding healthcare funding. Inserting clinical insights into reimbursement methodologies can lead to affordability and improved patient outcomes. Clinicians are well positioned to make a difference here. My passion is developing an engaged team, effective processes, and surrounding clinicians with the right technology, data, and market insights so they can work at the top of their licensure.
Dave Cardelle
Chief Strategy Officer
AMS
Dave Cardelle, R.Ph., is on the executive team at AMS and serves as the Chief Strategy Officer. He leads a dedicated team of professionals focused on transforming the payment integrity (PI) industry. With a BS in Pharmacy from the Massachusetts College of Pharmacy in Boston, MA, Dave brings a unique blend of healthcare expertise and domain knowledge to his role.
As the CSO, Dave leverages years of experience in the PI industry, including working for both Payer and Provider organizations to help AMS grow through innovative product, sales, marketing, and client relationship strategies.
Throughout his career, Dave has consistently demonstrated a keen understanding of healthcare-related matters, a skill that proves invaluable in the context of payment integrity. His passion for advancing the industry and commitment to maintaining the highest standards of integrity have earned him a reputation as a true industry expert.
AMS Intelligent Analytics
Website: www.amspredict.com
Advanced Medical Strategies (AMS) is a leading enterprise healthcare affordability platform that unifies the industry's most comprehensive payment, pricing, clinical, financial, and operational intelligence into a single AI-powered platform. By integrating payment integrity, price transparency, decision intelligence, risk management, clinical standards of care, reimbursement policy intelligence, financial benchmarking, statistically valid analytics, proprietary implant and medical device cost intelligence, and advanced healthcare data, AMS helps healthcare organizations improve payment accuracy, reduce unnecessary spending, and strengthen financial performance.
AMS empowers organizations to prevent, identify, and recover overpayments across pre-payment and post-payment workflows while delivering transparent insights that address the root causes of payment errors, improve reimbursement strategies, strengthen policy governance, support more competitive provider contracting, enhance fiduciary oversight, and advance enterprise healthcare affordability. By transforming complex healthcare data into actionable intelligence, AMS enables clinical, financial, payment integrity, contracting, compliance, and executive leaders to make more informed decisions that improve operational performance, financial outcomes, and healthcare affordability across the healthcare ecosystem.
