Payment integrity is evolving from a downstream claims audit function to a proactive, critical lever for upstream cost avoidance. Payment integrity leaders note that ‘shifting left’ can cut administrative duties by at least 10-15%, in addition to improving provider abrasion. But evolving to cost avoidance not only requires a shift in mindset, but an evolution in how data, AI tools, and cross-functional collaboration are used to enable proactive decision making.

• Case studies: Critical strategies for launching pre-pay programs and measuring ROI
• How AI is expanding pre-pay capabilities and required governance
• Rethinking the impact and attribution of provider education initiatives

In partnership with Optum

The payment integrity vendor landscape has expanded rapidly, with plans now juggling specialist partners across pre-pay, post-pay, DRG validation, COB, FWA, clinical review, and an ever-growing list of AI-enabled point solutions. While each vendor promises incremental savings, the cumulative cost of sourcing, contracting, onboarding, integrating, and reconciling reporting across a sprawling stack is becoming a payment integrity problem in its own right. This panel brings together PI leaders who have wrestled with rationalising their vendor ecosystems to share practical approaches for building a leaner, better-orchestrated, and easier-to-manage vendor stack without losing savings yield.

• How to evaluate and source new vendors efficiently, including which proof points and pilot structures actually predict in-production performance
• Designing a waterfall and integration model that minimises duplicate findings, claim leakage, and operational drag across multiple vendors
• Consolidating vendor reporting and KPIs into a single view so PI leaders can defend total program value to senior leadership

Code updates. Site-of-service rule changes. Specialty drug billing classifications. Telehealth policy still being written. Coding technology evolving. The environment that edit programs have to keep up with in 2026 is more complex than it has ever been, and an annual review cycle is not enough. This session looks at what a well-governed, modern, continuously maintained edit program looks like in practice, where the most costly gaps tend to open and how technology can keep your plan ahead. 

• How to build an edit governance process that keeps pace with frequent policy changes across multiple lines of business
• Where the highest-risk edit gaps are opening right now and how to prioritise closing them without expanding every programme at once
• How to defend edits in provider disputes when the underlying policy they are based on is itself in transition

In partnership with Shift Technology

Key discussion points:

• How state agencies and managed care organisations can build collaborative infrastructure to facilitate information exchange among MCO SIUs, oversight bodies, actuaries, and auditors
• Impact of shared information exchange on anomaly detection, high risk providers, and overpayment management
• How improved collaboration impacted managed care rate setting

Key discussion points:
- How state agencies and managed care organisations can build collaborative infrastructure to facilitate information exchange among MCO SIUs, oversight bodies, actuaries, and auditors
- Impact of shared information exchange on anomaly detection, high risk providers, and overpayment management
- How improved collaboration impacted managed care rate setting

Key discussion points:
- How state agencies and managed care organisations can build collaborative infrastructure to facilitate information exchange among MCO SIUs, oversight bodies, actuaries, and auditors
- Impact of shared information exchange on anomaly detection, high risk providers, and overpayment management
- How improved collaboration impacted managed care rate setting

As AI adoption accelerates across clinical documentation, coding, and billing workflows, health plans are facing new challenges balancing claims accuracy, operational efficiency, and provider collaboration. Join Alaffia for a candid discussion on how AI-driven claims intelligence can help plans address emerging upcoding risk, improve oversight in high-impact areas, and move closer to a shared source of truth across the claims lifecycle.

• Where health plans are seeing the most volatility in complex, high-dollar claims such as sepsis
• How plans are adapting review and oversight models in an AI-enabled environment while reducing provider abrasion
• How clinician-informed, agentic AI can support scalable payment integrity and workflow automation across pre-pay and post-pay settings
• How payers can use AI to improve coding accuracy, strengthen payer-provider alignment, and support defensible outcomes

In partnership with Alaffia Health