Track 1: Advanced Payment Integrity Function
- Gain a comprehensive understanding of the fundamentals of artificial intelligence and its applications in payment integrity.
- Explore essential strategies for implementing AI in payment integrity operations to improve efficiency and accuracy – especially when lack of resources is a struggle.
- Learn from case studies about successful AI implementations and practical strategies for leveraging AI technologies.
Track 2: Developing Payment Integrity Function
- Explore some of the most effective uses of AI in Payment Integrity and understand its benefits.
- Highlight the role of AI in identifying fraudulent activities and streamlining fraud detection workflows.
- Learn about the specific processes within fraud identification where AI can make a significant contribution and where human input remains essential.
Track 1: Advanced Payment Integrity Function
- Learn effective strategies for recruiting and training payment integrity experts to build a high-performing team.
- Understand where to recruit talent from and how to identify individuals with the necessary skills for payment integrity roles.
- Gain insights into developing and nurturing payment integrity talent for long-term success.
Track 2: Developing Payment Integrity Function
- Learn how to develop a patient-centric claims management strategy that prioritizes inclusivity and transparency.
- Explore best practices for managing inpatient claims so as to enhance the patient experience.
- Understand the importance of inclusive claim management strategies in achieving payment integrity goals.
Track 1: Advanced Payment Integrity Function
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.
Drew Satriano
Vice President of Payment Integrity
Highmark Health
Drew Satriano, a seasoned professional with an MBA, CPA, CFE, and JD, brings extensive expertise in payment integrity, accounting, auditing, and legal matters within regulated environments. Notably, he has spearheaded innovative initiatives resulting in a 968% increase in savings since 2014. His recent focus includes leveraging AI and technology for enhanced accuracy and efficiency in provider payment processes.
- Gain a comprehensive understanding of payment integrity functions and the initial steps required to establish a payment integrity team.
- Learn about vendor setup and staffing strategies essential for building a successful payment integrity function.
- Understand the fundamentals of payment integrity
Track 2: Developing Payment Integrity Function
Monique Pierce
Head of Payment Integrity
Devoted 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.
Danielle Nelson
FWA Program Manager
PacificSource Health Plan
Danielle M. Nelson graduated from the University of Missouri with a Bachelor of Science in Criminology and Criminal Justice. In 2017, she received a Master of Arts in Management and Leadership from Webster University.
Prior to joining for PacificSource Health Plans (PacificSource) as the Fraud, Waste and Abuse Program Manager in 2022, Ms. Nelson spent seven years working in Special Investigations Units (SIU) of varying sizes at both for-profit and not-for profit organizations, allowing her to gain experience in investigating fraud for government-funded programs, ACA, FEHB, and commercial lines of business. Before moving into fraud investigations in health care, Ms. Nelson spent 15 years in finance, working in consumer lending and back-office operations.
Ms. Nelson is a member of the Association of Certified Fraud Examiners, the St. Louis Chapter of ACFE, and National Health Care Anti-Fraud Association (NHCAA) and a participant with the Healthcare Fraud Prevention Partnership (HFPP).
Danielle Nelson
FWA Program Manager
PacificSource Health Plan
Danielle M. Nelson graduated from the University of Missouri with a Bachelor of Science in Criminology and Criminal Justice. In 2017, she received a Master of Arts in Management and Leadership from Webster University.
Prior to joining for PacificSource Health Plans (PacificSource) as the Fraud, Waste and Abuse Program Manager in 2022, Ms. Nelson spent seven years working in Special Investigations Units (SIU) of varying sizes at both for-profit and not-for profit organizations, allowing her to gain experience in investigating fraud for government-funded programs, ACA, FEHB, and commercial lines of business. Before moving into fraud investigations in health care, Ms. Nelson spent 15 years in finance, working in consumer lending and back-office operations.
Ms. Nelson is a member of the Association of Certified Fraud Examiners, the St. Louis Chapter of ACFE, and National Health Care Anti-Fraud Association (NHCAA) and a participant with the Healthcare Fraud Prevention Partnership (HFPP).
Learn how one health plan worked to implement both primary care capitation and global capitation in their market. The healthplan will explain how they leveraged their provider relationships to develop capitation models, configured their systems to pay capitation and were able to deepen the collaboration with providers.
1. Learn how to leverage your system capabilities and data to implement capitation.
2. Explore better strategies to collaborate with providers implementing payment change.
3. Understand how to measure success under a capitated contract.
Track 1: Advanced Payment Integrity Function
Cathy Newman
Managing Director Value-Based Strategy
Blue Cross Blue Shield of Rhode Island
Cathy Newman is the Managing Director of Value-Based strategy for Blue Cross Blue Shield of Rhode Island. Her experience in the healthcare industry spans over twenty years working for both large integrated providers, small IPAs, and health plans. In her ten years with Blue Cross, she has worked to advance value-based opportunities from pay for performance to full-risk global capitation models. She is passionate about her work and has been able to develop more collaborative and meaningful relationships with providers throughout the state of Rhode Island.
- Understand the role of payers, providers, CMS, and PBMs in effectively combatting pharmacy fraud.
- Learn strategies for identifying fraudulent prescriptions and reducing waste through collaborative efforts.
- Explore ways to establish effective communication networks between these groups to prevent duplicate claims.
Michael Devine
Director Special Investigations Unit
L.A Care
- Gain insights into the effects of regulatory changes on payment and revenue integrity operations.
- Learn the impact of innovations, such as automation, on the work of these organisations and how they will improve processes.
- Discuss strategies for cost containment while still accounting for the need to reduce provider abrasion in the evolving regulatory landscape.
Dale Carr
Director
Missouri Medicaid Audit and Compliance (MMAC)
Dale Carr currently serves as Director of the Missouri Medicaid Audit & Compliance (MMAC) unit, which
has overall responsibility for Medicaid program integrity efforts. Dale has worked for the State of
Missouri since 2011. Director Carr was previously a Police Officer in Fallon, NV; an Investigator for the
U.S. Office of Special Counsel; and a Supervisory Special Agent with the Coast Guard Investigative
Service. Dale holds a Bachelor’s degree in Administration of Criminal Justice and is a graduate of the
158th Session of the FBI National Academy.
Drew Satriano
Vice President of Payment Integrity
Highmark Health
Drew Satriano, a seasoned professional with an MBA, CPA, CFE, and JD, brings extensive expertise in payment integrity, accounting, auditing, and legal matters within regulated environments. Notably, he has spearheaded innovative initiatives resulting in a 968% increase in savings since 2014. His recent focus includes leveraging AI and technology for enhanced accuracy and efficiency in provider payment processes.