Healthcare Payment & Revenue Integrity Congress East 2023 Agenda | Kisaco Research

Welcome to the 2nd Annual HPRI Congress East in Boston!

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Wednesday, 13 Sep, 2023
9:00am

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

Author:

Ritesh Ramesh

Chief Executive Officer
MDAudit
... read more

Ritesh Ramesh

Chief Executive Officer
MDAudit

Author:

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.

... read more

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.

Author:

Dave Cardelle

Chief Strategy Officer
AMS
... read more

Dave Cardelle

Chief Strategy Officer
AMS
9:45am

Discussion of major trends shaping the future of Payment Integrity, including technological innovation (e.g., Generative AI) and reimbursement innovation (e.g., VBC)

Author:

Mahi Rayasam

PhD., Partner
McKinsey

Mahi Rayasam is a Partner in McKinsey’s Healthcare practice and leads a large analytics team focused on Healthcare Affordability, Quality and Outcomes. Mahi serves payers, healthcare technology & services companies and private equity institutions on topics related to transformations, operations and innovation. Specifically, Mahi has extensive experience in serving payers across 30 states on topics including Payment Integrity, FW&A, Medical Management and Out-of-Network cost management. Mahi also leads the development of McKinsey’s knowledge and product development efforts on AI/ML/NLP and other transformative technologies for healthcare.

... read more

Mahi Rayasam

PhD., Partner
McKinsey

Mahi Rayasam is a Partner in McKinsey’s Healthcare practice and leads a large analytics team focused on Healthcare Affordability, Quality and Outcomes. Mahi serves payers, healthcare technology & services companies and private equity institutions on topics related to transformations, operations and innovation. Specifically, Mahi has extensive experience in serving payers across 30 states on topics including Payment Integrity, FW&A, Medical Management and Out-of-Network cost management. Mahi also leads the development of McKinsey’s knowledge and product development efforts on AI/ML/NLP and other transformative technologies for healthcare.

Author:

Pooja Singh

Partner
McKinsey

Pooja Singh is a Partner in McKinsey’s Healthcare practice and a leader in the domain focused on Healthcare Affordability, Quality and Outcomes. Pooja serves payers, healthcare technology & services companies and private equity institutions on topics related to transformations, operations and innovation. Specifically, Pooja has extensive experience in serving payers on topics including Payment Integrity, FW&A, Medical Management, Care Management and Network management.

... read more

Pooja Singh

Partner
McKinsey

Pooja Singh is a Partner in McKinsey’s Healthcare practice and a leader in the domain focused on Healthcare Affordability, Quality and Outcomes. Pooja serves payers, healthcare technology & services companies and private equity institutions on topics related to transformations, operations and innovation. Specifically, Pooja has extensive experience in serving payers on topics including Payment Integrity, FW&A, Medical Management, Care Management and Network management.

10:15am

- This session will be focused on providing an insider’s view of CPI and CPI’s 2023 priorities
- We will cover the use of the Government Accountability Office Fraud Risk Management Framework to develop anti-fraud strategies and react to emerging threats, updates on our Marketplace fraud work, and opportunities for private-public collaboration.

Payment Integrity

Author:

Jennifer Dupee

Director, Audit & Vulnerabilities Group, Center for Program Integrity
CMS

Jennifer Dupee, Director. Audits & Vulnerabilities Group. Center for Program Integrity

In her role as the Director of the Audits and Vulnerabilities Group, Ms. Dupee identifies and develops comprehensive mitigation strategies addressing program integrity risks for all of CMS' programs, provides oversight of Medicare Part C and Part D plans and the Federally Facilitated Exchanges, and implements CMS’ Comprehensive Medicaid Integrity Plan. Prior to her current role at CPI, Ms. Dupee worked on such initiatives as the improper payment rate measurement for the Medicare fee-for-service program, Open Payments, and the Healthcare Fraud Prevention Partnership. Ms. Dupee also completed a Congressional detail with the House Committee on Ways and Means, responsible for a portfolio of Medicare fee-for-service and program integrity issues. Ms. Dupee has a Bachelor of Science Degree in Nursing from the University of Wisconsin, a Master of Science in Nursing and a Master of Business Administration from Johns Hopkins University, and a Juris Doctor Degree with a Health Law Certificate from the University of Maryland. 

... read more

Jennifer Dupee

Director, Audit & Vulnerabilities Group, Center for Program Integrity
CMS

Jennifer Dupee, Director. Audits & Vulnerabilities Group. Center for Program Integrity

In her role as the Director of the Audits and Vulnerabilities Group, Ms. Dupee identifies and develops comprehensive mitigation strategies addressing program integrity risks for all of CMS' programs, provides oversight of Medicare Part C and Part D plans and the Federally Facilitated Exchanges, and implements CMS’ Comprehensive Medicaid Integrity Plan. Prior to her current role at CPI, Ms. Dupee worked on such initiatives as the improper payment rate measurement for the Medicare fee-for-service program, Open Payments, and the Healthcare Fraud Prevention Partnership. Ms. Dupee also completed a Congressional detail with the House Committee on Ways and Means, responsible for a portfolio of Medicare fee-for-service and program integrity issues. Ms. Dupee has a Bachelor of Science Degree in Nursing from the University of Wisconsin, a Master of Science in Nursing and a Master of Business Administration from Johns Hopkins University, and a Juris Doctor Degree with a Health Law Certificate from the University of Maryland. 

10:45am
  1. Automation frees your Plan’s content from processors, auditors, analysts, and even your vendors. It’s your content.
  2. Query, add exclusions, conduct research, identify new edits and ideas. It’s your content.
  3. Enjoy claim audits that are 26x faster than manual workflows – at less than half the cost – while maintaining > 96% agreement with human review.

Author:

Dutch Noss

Chief Operating Officer
Precision GX

Dutch Noss, COO of PrecisionGx is a highly versed Operations leader with 20+ years in Payment Integrity, Revenue Cycle Management, and Product Development. Dutch is an expert in the operational use of Artificial Intelligence, Machine Learning, Predictive Analysis, and Gaming Theory. Dutch’s specialties span both clinical and non-clinical audits including Contract Compliance, Duplicate Payments, IBill & DRG Review, COB, TPL, Retro-term, FWA and RAC audits in pre and post pay settings for Commercial, Medicare, and Medicaid payers.”

... read more

Dutch Noss

Chief Operating Officer
Precision GX

Dutch Noss, COO of PrecisionGx is a highly versed Operations leader with 20+ years in Payment Integrity, Revenue Cycle Management, and Product Development. Dutch is an expert in the operational use of Artificial Intelligence, Machine Learning, Predictive Analysis, and Gaming Theory. Dutch’s specialties span both clinical and non-clinical audits including Contract Compliance, Duplicate Payments, IBill & DRG Review, COB, TPL, Retro-term, FWA and RAC audits in pre and post pay settings for Commercial, Medicare, and Medicaid payers.”

11:15am
12:00pm
  • 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

Author:

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.

... read more

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.

- 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

Author:

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.

... read more

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.

12:30pm
  • A focus on the core pieces of FWAE vs. PI and how to bridge the gap within each payer's organization.
  • Understanding the key differences between Payment Integrity and Special Investigation Units.
  • Contemplate their current organizational structure surrounding PI and SIU and assess potential gaps and/or overlaps.
  • Reassess existing tools used to capture overpayments.
Payment Integrity

Author:

Karen Weintraub

Executive Vice President
HEALTHCARE FRAUD SHIELD

With 25 years of data and 20 years of healthcare experience, Ms. Weintraub is currently responsible for the design and development of the company’s healthcare fraud detection software products and services. She provides subject matter expertise on system design and workflow, business rule development, data mining and fraud outlier algorithms as well as SIU policies and procedures. Prior to joining Healthcare Fraud Shield, managed SIUs on various healthcare investigations for all commercial, Medicaid and Medicare business and claims of fraudulent activity. Ms. Weintraub received a BA in Criminal Justice from the University of Delaware and an MA in Criminal Justice from Rutgers University. Ms. Weintraub is a Certified Professional Coder for Payers (CPC-P), a Certified Professional Medical Auditor (CPMA) from the American Academy of Professional Coders, a Certified Dental Coder (CDC) from the American Dental Association, and the founder of the Hamilton, NJ AAPC chapter. She is also an Accredited Healthcare Fraud Investigator (AHFI) from the National Healthcare Anti-Fraud Association (NHCAA). Ms. Weintraub Taught CPT Coding, Fraud & Audits, and Medical Billing, Laws and Ethics and the local community college. 

... read more

Karen Weintraub

Executive Vice President
HEALTHCARE FRAUD SHIELD

With 25 years of data and 20 years of healthcare experience, Ms. Weintraub is currently responsible for the design and development of the company’s healthcare fraud detection software products and services. She provides subject matter expertise on system design and workflow, business rule development, data mining and fraud outlier algorithms as well as SIU policies and procedures. Prior to joining Healthcare Fraud Shield, managed SIUs on various healthcare investigations for all commercial, Medicaid and Medicare business and claims of fraudulent activity. Ms. Weintraub received a BA in Criminal Justice from the University of Delaware and an MA in Criminal Justice from Rutgers University. Ms. Weintraub is a Certified Professional Coder for Payers (CPC-P), a Certified Professional Medical Auditor (CPMA) from the American Academy of Professional Coders, a Certified Dental Coder (CDC) from the American Dental Association, and the founder of the Hamilton, NJ AAPC chapter. She is also an Accredited Healthcare Fraud Investigator (AHFI) from the National Healthcare Anti-Fraud Association (NHCAA). Ms. Weintraub Taught CPT Coding, Fraud & Audits, and Medical Billing, Laws and Ethics and the local community college. 

Revenue Integrity

Author:

Niobis Queiro

CEO
The Queiro Group

Niobis (Nio) Queiro is the founder of The Queiro Group offering transformation, integration, advisory and leadership development services.  Nio formerly was the SVP of Revenue Cycle Tufts Medicine, in Boston Massachusetts. 

She brings vast experience in both the hospital and physician revenue cycle industry. Nio uses her expertise in Lean and Six Sigma to drive change across diverse healthcare delivery channels, hence, bridging the chasm between finance and clinical care.  As a change agent she has been able assist health systems transition to an integrated revenue cycle that met or exceeded HFMA KPI standards. Nio has presented in front of Congress as an industry expert for the digitization of the military service men medical records as the lead of a proof-of-concept project that is now the standard healthcare data exchange for the military.   Nio was named as one of the top 25 Innovators of 2021 by Modern Healthcare.

Niobis continues her dedication to education as an adjunct Professor with Tufts University’s Masters in Public Health program and as a Professional Coach, business advisor. For fun its all about family and spoiling her grandson, Cylas.

... read more

Niobis Queiro

CEO
The Queiro Group

Niobis (Nio) Queiro is the founder of The Queiro Group offering transformation, integration, advisory and leadership development services.  Nio formerly was the SVP of Revenue Cycle Tufts Medicine, in Boston Massachusetts. 

She brings vast experience in both the hospital and physician revenue cycle industry. Nio uses her expertise in Lean and Six Sigma to drive change across diverse healthcare delivery channels, hence, bridging the chasm between finance and clinical care.  As a change agent she has been able assist health systems transition to an integrated revenue cycle that met or exceeded HFMA KPI standards. Nio has presented in front of Congress as an industry expert for the digitization of the military service men medical records as the lead of a proof-of-concept project that is now the standard healthcare data exchange for the military.   Nio was named as one of the top 25 Innovators of 2021 by Modern Healthcare.

Niobis continues her dedication to education as an adjunct Professor with Tufts University’s Masters in Public Health program and as a Professional Coach, business advisor. For fun its all about family and spoiling her grandson, Cylas.

1:00pm
2:30pm
3:00pm
  • Coordinating the efforts of credentialing/enrollment, audits, investigations (SIUs), provider sanctions, and policy
  • Very few insurance payers have all those groups working together in a coordinated effort to reduce fraud, increase revenue, and render excellent customer service to enrolled health care providers.
Track 1: Payment Integrity

Author:

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.

... read more

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.

3:30pm
4:00pm
  • Scaling Payment Integrity operations through digital capabilities and automation
  • The impact of Generative AI to Payment Integrity operations

Author:

William O'Neill

Vice President – Product Management, Payment Integrity
EXL
... read more

William O'Neill

Vice President – Product Management, Payment Integrity
EXL
4:30pm

- A discussion between key payers and providers to communicate share challenges and concerns
- Case studies of successful payer-provider initiatives and effective provider engagement strategies
- Progressing mutually beneficial initiatives in a collaborative manner

Payment Integrity
Revenue Integrity

Author:

Andrea Beatrice

Director of Payment Integrity and FWA
Health New England
... read more

Andrea Beatrice

Director of Payment Integrity and FWA
Health New England

Author:

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.

... read more

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.

5:00pm
Thursday, 14 Sep, 2023
9:00am
Payment Integrity
Speakers

Author:

Phillip Churchill

Assistant General Counsel
Blue Cross Blue Shield of Michigan
... read more

Phillip Churchill

Assistant General Counsel
Blue Cross Blue Shield of Michigan

Author:

Aaron Browder

President
Carelon Subrogation

Aaron Browder is Staff Vice President, Elevance Health and President, Carelon Subrogation, formerly Meridian Resource Company (Meridian), where he and his team are responsible for overseeing the successful implementation and execution of our clients’ end-to-end subrogation programs. With a nearly 20-year career in subrogation, Aaron possesses a deep knowledge of healthcare subrogation. He has held a wide range of management positions throughout his tenure at Meridian, most recently serving as Staff Vice President. Prior to joining Meridian, Aaron gained experience in the financial services and insurance industries with Arthur Andersen, LLP/KPMG, LLP, and Travelers Property Casualty.

Aaron holds a Bachelor of Arts degree from Indiana University and a Master of Business Administration from Butler University. He served on the Board of Directors for the National Association of Subrogation Professionals and has been a national presenter and author on issues related to subrogation.

 

... read more

Aaron Browder

President
Carelon Subrogation

Aaron Browder is Staff Vice President, Elevance Health and President, Carelon Subrogation, formerly Meridian Resource Company (Meridian), where he and his team are responsible for overseeing the successful implementation and execution of our clients’ end-to-end subrogation programs. With a nearly 20-year career in subrogation, Aaron possesses a deep knowledge of healthcare subrogation. He has held a wide range of management positions throughout his tenure at Meridian, most recently serving as Staff Vice President. Prior to joining Meridian, Aaron gained experience in the financial services and insurance industries with Arthur Andersen, LLP/KPMG, LLP, and Travelers Property Casualty.

Aaron holds a Bachelor of Arts degree from Indiana University and a Master of Business Administration from Butler University. He served on the Board of Directors for the National Association of Subrogation Professionals and has been a national presenter and author on issues related to subrogation.

 

Moderator

Author:

Kyle Pankey

Sales & Growth Leader
Carelon Subrogation

Kyle Pankey has over two decades of experience working within the healthcare and payer operations, with over 10 years specifically tied in to the payment integrity space.   Kyle lives in Chattanooga, TN and has served as Carelon Subrogation’s growth leader since mid-2022.

... read more

Kyle Pankey

Sales & Growth Leader
Carelon Subrogation

Kyle Pankey has over two decades of experience working within the healthcare and payer operations, with over 10 years specifically tied in to the payment integrity space.   Kyle lives in Chattanooga, TN and has served as Carelon Subrogation’s growth leader since mid-2022.

9:30am
  1. Highlighting key pain points that healthcare organizations face in PI operations and how it impacts their operations
  2. Picture what other payer organization are doing to alleviate the pain points
  3. Talking about “what if” scenarios or successful use cases of technology, process, governance to help in PI operations
Payment Integrity

Author:

Ankur Verma

Vice President, Healthcare
Everest
... read more

Ankur Verma

Vice President, Healthcare
Everest
10:00am
11:00am

- Complement your staff with data mining experts who identify hard to find claim overpayments.
- Stay ahead of constant claim leakage. Use expertise to detect new savings opportunities.
- Improve your medical loss ratio: Return claim dollars to your team/company/bottom line.

Payment Integrity

Author:

Kathy Gonzales-Byrd

Chief Strategy Officer
MedReview

Kathy Gonzales is the Chief of Staff, collaborating with the CEO and other senior leaders on revenue growth, process improvement and organizational effectiveness. Kathy oversees new client implementations and operations for key strategic accounts; manages the organization’s strategic planning process; and oversees interdepartmental accountability processes to ensure operational efficiency.

Before joining MedReview’s senior leadership team, Kathy served as Vice President, Payment Recovery for Cotiviti, Inc. overseeing claim audit operations and client management for Blue Cross Blue Shield accounts. She also has a long-standing consulting career, which include leadership roles in healthcare revenue cycle and organization effectiveness with Accenture and Ernst & Young.

Kathy has a bachelor’s degree in psychology from West Chester University of Pennsylvania, and a master’s degree in business administration (MBA) and Health Care Administration and Finance from Widener University.

 

... read more

Kathy Gonzales-Byrd

Chief Strategy Officer
MedReview

Kathy Gonzales is the Chief of Staff, collaborating with the CEO and other senior leaders on revenue growth, process improvement and organizational effectiveness. Kathy oversees new client implementations and operations for key strategic accounts; manages the organization’s strategic planning process; and oversees interdepartmental accountability processes to ensure operational efficiency.

Before joining MedReview’s senior leadership team, Kathy served as Vice President, Payment Recovery for Cotiviti, Inc. overseeing claim audit operations and client management for Blue Cross Blue Shield accounts. She also has a long-standing consulting career, which include leadership roles in healthcare revenue cycle and organization effectiveness with Accenture and Ernst & Young.

Kathy has a bachelor’s degree in psychology from West Chester University of Pennsylvania, and a master’s degree in business administration (MBA) and Health Care Administration and Finance from Widener University.

 

11:30am
12:00pm
  • Defining Clinical Validation
  • Coding Guidelines vs CMS Guidelines
  • Common Conditions for Clinical Validation
  • Monetary Savings and Case Studies
Payment Integrity

Author:

Katreece Baker

VP of Clinical Operations
DRG Claims Management
... read more

Katreece Baker

VP of Clinical Operations
DRG Claims Management
12:30pm
1:30pm

101 for modernization of each step of the claims continuum. 4 separate discussion across:

There are limited seats on each roundtable, so we recommend you reserve your space as soon as possible. Please select two (email [email protected] to reserve).

A) Itemized Bill Reviews
Moderator: Toni Case, Vice President National Sales, Ceris

B) Price Transparency
Moderator: Dave Cardelle, Chief Strategy Officer, Advanced Medical Solutions

C) The Changing World of Payment Integrity As it Relates to Value Based Care
Moderator: Lacey Crowl, Director, Claims Operations, Longevity Health Plan

D) Leverage Data Sources To Assure Membership Data Accuracy
Moderator: Morgan Tackett, Vice President Product, CAQH & Sherri Richardson, Strategy & Program Director, COB, Carelon

E) Top 3 ways to handle provider abrasion and manage clinical expenses
Moderator: Bob Starman, SVP Payment Integrity Solutions, Sagility 

Payment Integrity
Revenue Integrity
Moderators

Author:

Lacey Crowl

VP of Health Plan Operations
Longevity Health Plan

Lacey Crowl is the Director of Claims Operations for Longevity Health Plan, responsible for the accuracy of claims processing focused on Medicare members. Lacey has experience in the Commercial, Medicare and Medicaid environments, developing prospective and retrospective payment integrity solutions for both clinical and claim coding reviews. She has operated within various claims processing platforms to develop, code and implement new audit concepts while operating within the Managed Care space.

... read more

Lacey Crowl

VP of Health Plan Operations
Longevity Health Plan

Lacey Crowl is the Director of Claims Operations for Longevity Health Plan, responsible for the accuracy of claims processing focused on Medicare members. Lacey has experience in the Commercial, Medicare and Medicaid environments, developing prospective and retrospective payment integrity solutions for both clinical and claim coding reviews. She has operated within various claims processing platforms to develop, code and implement new audit concepts while operating within the Managed Care space.

Author:

Toni Case

Vice President, National Sales
CERIS
... read more

Toni Case

Vice President, National Sales
CERIS

Author:

Morgan Tackett

Vice President Product
CAQH

Morgan Tackett is Vice President Product at CAQH.  Over the last nine years, he has worked to build the portfolio of member and provider data solutions that CAQH offers to the industry. Prior to joining CAQH, Morgan spent 18 years at Blue Cross and Blue Shield of North Carolina, where he led teams in Member Service Operations, EDI Services, and Network Management.  Morgan holds an MPH from the University of North Carolina at Chapel Hill.

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Morgan Tackett

Vice President Product
CAQH

Morgan Tackett is Vice President Product at CAQH.  Over the last nine years, he has worked to build the portfolio of member and provider data solutions that CAQH offers to the industry. Prior to joining CAQH, Morgan spent 18 years at Blue Cross and Blue Shield of North Carolina, where he led teams in Member Service Operations, EDI Services, and Network Management.  Morgan holds an MPH from the University of North Carolina at Chapel Hill.

Author:

Sherri Richardson

Strategy, Growth and Program Director
Carelon

As a strategic leader in Program Integrity Health Insurer industry and having mastered the world of “coordination of benefits”, Sherri is passionate about helping our customers and peers navigate the complex world of healthcare. With a proven track record of success in optimizing program efficiency and minimizing cost of care for Members who are eligible/entitled to two health coverages, Sherri is dedicated to ensuring the industry processes are focused on minimizing members out of pocket and provider/insurers administrative costs.

Sherri has 30+ years Health Insurer Industry experience. Operational Excellence, mapping program Strategy is Her Leadership background includes leading highly productive operational teams and all functions of COB Operations within the Commercial, Medicare, Affordable Care Act, Medicaid, Subrogation and Senior market.

As an Elevance/Carelon Corporate Presenter, Sherri enjoys developing training and motivational material, as well as sharing her knowledge and best practices related to maximizing Health Coverage with members, groups, providers and other insurer peers.

Sherri’s experience in health insurance runs deeps, having the privilege of leadership at Elevance/Carelon for 30+ years, and mentoring from industry leaders. Sherri is a life-long learner and strongly encourages others to learn and grow through continued experiences and educational opportunities.

On a personal note; As a prior Fitness Trainer, Sherri enjoys Weight Training, Yoga, Aerial Silks, and Master Swimming.  Oftentimes joins the local 5K runs and loves to cook.   

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Sherri Richardson

Strategy, Growth and Program Director
Carelon

As a strategic leader in Program Integrity Health Insurer industry and having mastered the world of “coordination of benefits”, Sherri is passionate about helping our customers and peers navigate the complex world of healthcare. With a proven track record of success in optimizing program efficiency and minimizing cost of care for Members who are eligible/entitled to two health coverages, Sherri is dedicated to ensuring the industry processes are focused on minimizing members out of pocket and provider/insurers administrative costs.

Sherri has 30+ years Health Insurer Industry experience. Operational Excellence, mapping program Strategy is Her Leadership background includes leading highly productive operational teams and all functions of COB Operations within the Commercial, Medicare, Affordable Care Act, Medicaid, Subrogation and Senior market.

As an Elevance/Carelon Corporate Presenter, Sherri enjoys developing training and motivational material, as well as sharing her knowledge and best practices related to maximizing Health Coverage with members, groups, providers and other insurer peers.

Sherri’s experience in health insurance runs deeps, having the privilege of leadership at Elevance/Carelon for 30+ years, and mentoring from industry leaders. Sherri is a life-long learner and strongly encourages others to learn and grow through continued experiences and educational opportunities.

On a personal note; As a prior Fitness Trainer, Sherri enjoys Weight Training, Yoga, Aerial Silks, and Master Swimming.  Oftentimes joins the local 5K runs and loves to cook.   

Author:

Bob Starman

SVP Payment Integrity Solutions
Sagility
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Bob Starman

SVP Payment Integrity Solutions
Sagility

Author:

Dave Cardelle

Chief Strategy Officer
AMS
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Dave Cardelle

Chief Strategy Officer
AMS
2:30pm
3:00pm

Join us for an insightful session with closing remarks led by industry expert Dave Cardelle. Explore the dynamic landscape of Payment Integrity (PI) and Business Intelligence (BI) trends, the strategic use of AI and technology, and the emerging concept of Price Transparency in the healthcare sector. In this engaging presentation, you'll gain valuable insights into how these elements intersect and how they can positively impact provider and payer collaborations, particularly in predicting and managing denials.

  • PI & BI Trends In-Source vs. Out-Source
    The session kicks off with an exploration of the evolving trends of outsourcing and insourcing within the healthcare industry and how organizations are harnessing data and new technology to optimize their operations, streamline processes, and make informed decisions using BI to drive better payment accuracy,
  • Leveraging AI & Technology for PI & BI
    In today's healthcare landscape, the power of improved technology cannot be overstated. Discover how advanced technology-based solutions are transforming the path to payment accuracy.
  • New Concepts in Price Transparency for PI & BI
    Price Transparency is an emerging concept that is reshaping the way healthcare services are billed and paid for. An overview of the importance of transparency in healthcare pricing and how it's becoming a game-changer for both providers and payers.
  • Collaborative Approach using Predictive Analytics for BI & PI
    Finally, the session will conclude with a deep dive into predictive analytics as a tool for managing and mitigating Provider denials that helps both Provider and Payers manage their business more efficiently.
Payment Integrity
Revenue Integrity

Author:

Dave Cardelle

Chief Strategy Officer
AMS
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Dave Cardelle

Chief Strategy Officer
AMS
3:30pm

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