Though steps are being taken to fight healthcare fraud, there is much more that can be done. We are seeing new schemes and repeated fraud practices happening within provider networks throughout the country as we work with CMS and health plans to combat these violations. Through our network of over 550 licensed field and desktop investigators we are able to identify these situations before they become a major risk to the payors.

Ray Evans and Chandra Kuti will discuss the ever-evolving healthcare system involving state and federal regulations constantly changing along with the significant increase in utilization in the post-pandemic environment. They will review how this increase in claims volumes will effect the vulnerability for health plans and ways to identify any FWA issues that may be flying under the radar.

For over 20 years, CoventBridge Group has served as a Fraud, Waste and Abuse program integrity contractor for The Center for Medicare and Medicaid Services investigating Medical Provider FWA in Medicare, Medicaid, and commercial lines of business.

Armed with proven analytics utilizing over two decades of FWA expertise, enhanced with our proprietary algorithms and machine learning capabilities, our mission is to assist health plans in protecting their organizations from FWA through an experienced, flexible, and sensitive approach to minimizing provider abrasion, while still achieving organizational objectives.

Join our discussion on what the future holds for FWA and tactics to leverage the BIG Three --- identify – investigate – recover.  

Discover how health plans can strategically embrace insourcing through Software-as-a-Service, regaining control of payment integrity reviews with an AI-driven platform. Join this breakout session to learn how Apixio supports teams at various readiness stages, developing configurable insourcing programs. Providing flexibility, our configurable SaaS platform is designed to meet health plans where they are in their payment integrity journey.

Innovative approaches to provider education, change in billing behaviour, and reduction in medical cost of care.

Alan Coulter will explain the history of how the payment integrity and revenue cycle issues with Coordination of Benefits began, provide examples of current problems, and what downstream impacts can occur if COB issues are not addressed at the member, group, and claims level for both payers and providers. He will also provide some tips for healthcare insurance companies wishing to maximize their processes to assist their provider partners and vice versa when caring for patients with multiple coverages.

While surgical implants are designed to be discreet and invisible for patients, for payers, implant costs can have a very noticeable impact on spending. Many health plans overpay for surgical implants due to lack of true cost transparency, national price variations, and incorrect billing for non-implantable items. The amount paid by health plans is often significantly higher than the provider’s true acquisition cost, equating to markups of 1,000% or more at times.

While off-the-shelf bill review solutions identify some savings, not all solutions are created equal. Comprehensive programs where the bill review process is managed end-to-end by industry experts and that are backed by the most up-to-date facility-specific implant cost data have been independently validated to deliver consistently greater savings.

Join this roundtable discussion to learn best practices for managing your surgical implant costs. We will cover what to look for when selecting a payment integrity partner to generate maximum cost savings, how to ensure durable and defensible savings that hold up through reconsiderations, and Paradigm’s industry-leading results. 

The roundtable will be hosted by Matt Ruyter, Senior Director of Product from Paradigm. Paradigm has reviewed over $2.3 billion in total implant charges, resulting in hundreds of millions of dollars of savings for our clients.