The healthcare landscape is fraught with complexity and financial pitfalls and small-to-medium-sized health plans often find themselves vulnerable to inflated claims, hemorrhaging millions annually.

Payment integrity products like DRG Coding and Clinical Validation, Hospital Bill Audits, Data Mining, and more, can offer immediate reinforcement against dubious claims. But which products should be deployed, when should they be implemented, what are the best practices for their utilization, and how do you effectively evaluate their impact?

In this session, discover how merging clinical expertise with AI technology enhances payment integrity solutions and evaluate in-house, outsourced, or combined approaches based on reassignment and appeal overturn rates for optimal financial protection.

In a world where healthcare fraud runs rampant and financial losses mount, a strategic plan for payment integrity stands as a beacon of hope for small to medium-sized health plans, offering a formidable defense against the forces of fiscal depletion. This discussion will provide a framework for developing a strategic approach to financial stability.

History of Hospital at Home and Telehealth Services
Post Pandemic Growth and Barriers
Hospital at Home vs Home Health

Reduced Payer and Provider Costs
Developing Reimbursement Policies
Identifying Potential Fraud, Waste and Abuse

Lesson objectives:

- Overall knowledge of hospital at home and telehealth services
- How to create effective reimbursement policies for emerging healthcare services

Every payer can agree on one thing. There is fraud, waste, and abuse happening that they cannot see or see fast enough with the limitations of current claims data-centric technology stacks. One more technology in the stack doesn't solve the problem of not being able to see dynamic behaviors, relationships, and outliers that lead to over-payments on basic CMS edits as well as undetected complex fraud and collusion schemes. More claims data-centric technology is not the solution. Dynamic provider-centric risk detection technology coupled with continuously-credentialed provider integrity data is the solution for increased FWA detection and near real-time prevention. That's because stacks of claim data-centric technologies (even those using conventional artificial intelligence) will never 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.

This session will focus on the benefits of a provider-centric FWA prevention approach powered by artificial intelligence that is dynamic and uses both supervised and unsupervised machine learning for detection beyond rules-based technologies. It will highlight strategies for FWA prevention at five points along the claims workflow including pre pre-payment, pre-payment, and post-payment positions. Fraud and SIU teams will be particularly interested in this combination of technologies to detect and automatically package fraud and collusion schemes you can’t see now or can’t see fast enough with the limitations of claim-centric approaches.

1. Understand the FWA detection limitations of claims data-centric approaches
2. Understand how a provider centric-approach such as Integr8 AI increases FWA detection and prevention
3. Understand the benefits of provider-centric FWA prevention pre pre-payment, pre-payment, and post-payment

• This session delves into prevalent billing and coding errors encountered in healthcare reimbursement postpayment and prepayent processes, shedding light on their potential to result in overpayments for payers. Through case studies and practical examples, Healthcare Fraud Shield can showcase effective strategies for identifying common errors, such as incorrect billing of maternity care services.
• This session will walk through:
• Appropriate coding for delivery services 
• Proper billing practices at it relates to antepartum and postpartum care 
• How to detect patterns of inappropriate claim submissions

HPRI developed a first of it's kind, payment integrity industry survey, in partnership with the payers that are part of the HPRI network. The survey results are aggregated to provide powerful insights from all of the PI experts across the country. The aim of the survey was to evaluate current trends in the payment integrity market, explore the payer perspective of implications related to the complexity of the market, and gain insights from payers on the introduction of disruptive technologies enabling greater analytics for unstructured data, and
opportunities for future savings in the coming year. Join us for a review of the 2024 PI survey results to help drive your PI initiatives.

- Learn about the most prominent PI trends for 2024
- Explore new innovations and their impact on driving 2024 opportunites
- Leverage survey results to asses where your program and organization fall in relation to your peers in the industry