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Session Topics:
Medical Cost Containment
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Wednesday, 5 Feb, 202507:30am08:30am
Payment Integrity Overview – A look at 2025
An overview of the most significant fraud trends and payment integrity technologies and strategies going into 2025.
Session Topics:Payment IntegritySponsor(s):MachinifySpeaker(s):
Kelly Bennett, JD, CFE, AHFI
State Medicaid Fraud and Abuse LeaderIndependentKelly Bennett graduated from the University of Tampa and Florida State University College of Law. She has been a member of the Florida Bar since 1997 and is a Certified Fraud Examiner and an Accredited Health Care Fraud Investigator. She has worked at the Florida Agency for Health Care Administration since 2001 and has served in several roles, including as a Senior Attorney within the Medicaid Division of the Office of the General Counsel, the Assistant Bureau Chief for the Bureau of Medicaid Program Integrity, the Agency’s Medicaid
Fraud Liaison, and is currently the Chief of Medicaid Program Integrity, where she has served since July of 2014. She is currently the President for the National Association for Medicaid Program Integrity and is an active participant in training and collaboration initiatives with the National Health Care Antifraud Association.
Dr. Priscilla Alfaro, MD, FAAP, CPC, CPMA, COC, CIC, CFE, CRC
VP Payment IntegrityBlue Cross NCDr. Priscilla Alfaro is a seasoned healthcare professional with extensive experience in executive medical management, fraud prevention, and healthcare analytics. A certified medical coder, fraud examiner, and auditor, she has a proven track record of improving healthcare efficiency and preventing fraud, waste, and abuse across various roles and affiliations, including the Texas HHS and Anthem.
Prasanna Ganesan
CEOMachinifyThe Denial Diagnosis: Uncovering Root Causes
- Gain insights into the current state of the RCM industry and understand the key challenges healthcare organizations face.
Learn how to identify and overcome clinical and technical denial triggers, potentially saving your organization millions in lost revenue.
- Walk away with actionable, data-driven techniques to analyze your denial trends, close process gaps and improve first-pass resolution rates.
Session Topics:Revenue Cycle ManagementSpeaker(s):
Lisa Meredith
AVP, Revenue Cycle ManagementLifePoint Health
Howard Kung
Senior Director, Revenue CycleMayo Clinic
Edward Marx
Chief Executive OfficerMarx AdvisoryThe youngest child of Holocaust survivors, Ed moved to the United States at age 10. At 16, he served as a medical clinic janitor where he discovered his healthcare calling. Ed took successive positions as combat medic, anesthesia tech, strategic planner and technology manager. He quickly learned how the convergence of clinical, business and digital saved lives. His passion ignited, he jumped feet first into technology and operations in the C-Suite of Cleveland Clinic, NYC Health & Hospitals, Texas Health Resources and University Hospitals.
Intermixed, Ed served the supplier side as well. He was CEO for consulting firm Divurgent, global CDO for Tech Mahindra Health & Life Sciences and CIO of the Advisory Board. Concurrently, he served 15 years as an Army combat engineer officer and combat medic. Today, Ed is focused on his own advisory practice.
Ed does a fair amount of speaking, writing and podcasting. He authored healthcare bestsellers including “Voices of Innovation” and “Healthcare Digital Transformation”. He is currently writing a book for Mayo Clinic on “Patient Experience” and “Voices of Innovation - Payers”. His podcast “DGTL Voices” is “Top 3%” globally. His Blog, CEO Unplugged, surpassed 1M views. Ed recently started a YouTube channel to expand his audience.
Most importantly, Ed is husband to Simran who holds a Doctor of Nursing (DNP). They love to dance and climb mountains. They have 5 grown children and 4 grandchildren. To stay fit, he is captain of TeamUSA Triathlon.
For more career information you can find me:
Twitter https://twitter.com/marxtango
LinkedIn https://www.linkedin.com/in/edwardmarx/
Website https://www.marxadvisory.com/
Becky Peters
Executive Director, Patient Access ServicesBanner Health
Rae A. McIntee, DDS, MD, MBA, FACS, CPE
Medical Director Clinical Solutions (Supporting Payment Integrity & SIU)Louisiana Blue09:00amInteroperability, the Cornerstone of Payment Integrity and Risk Adjustment Operations
In today’s complex healthcare ecosystem, interoperability - the seamless exchange and utilization of data across diverse systems - is the linchpin for success in payment integrity and risk adjustment. When health plans, payers, providers, and vendors collaborate through standardized and efficient data sharing, the results are transformative: accurate payments, fraud prevention, and streamlined processes that scale innovation. However, the absence of a disciplined interoperability strategy can lead to significant inefficiencies.
This keynote will emphasize the critical need for a proactive, stakeholder-driven interoperability plan. Drawing parallels to Six Sigma principles, it highlights how early standardization of data formats, security protocols, and transfer methods prevent downstream inefficiencies, reduce costs, and enhance scalability. Attendees will leave with actionable insights into how interoperability not only smooths immediate business processes but also lays the foundation for long-term industry transformation.
Join us to explore why interoperability isn’t just a technical challenge but a strategic imperative—an essential cornerstone for a resilient, innovative, and efficient healthcare system.Lesson Objectives:
- Understand the Impact of Interoperability: Learn how seamless data exchange and standardization, improve operational efficiency.
- Explore Real-World Lessons: Case studies help underscore the consequences of poor interoperability planning and the benefits of thoughtful standardization.
- Actionable Strategies for Stakeholder Collaboration: Discover how to develop a disciplined interoperability plan.Session Topics:Payment IntegritySponsor(s):AMS Intelligent AnalyticsSpeaker(s):
Dave Cardelle
Chief Strategy OfficerAMS09:30amCollaborating for Consistent Payment Integrity Metrics
This session will emphasize the importance of collaboration among stakeholders in developing and implementing consistent payment integrity metrics. Participants will explore strategies to improve data sharing, standardize measurement methodologies, and enhance fraud detection efforts.
Session Topics:Payment IntegritySponsor(s):6 Degrees HealthSpeaker(s):Moderator
Katherine Brant
President6 Degrees Health
Monique Pierce
Payment Solutions & OperationsCohere HealthMonique started her Payment Integrity career in COB at Oxford HealthPlans. After the merger with UnitedHealthcare, she led multiple teams and was responsible for creating innovative programs. Monique joined SCIO Health Analytics in 2014 and was responsible for system and process improvements before being promoted to VP of client engagement and business optimization In 2020, Monique joined start-up Devoted Health and created a full suite of programs from the ground up. Based on a passion for metrics and measuring performance, she centralized and standardized all programs reducing implementation time and maximizing savings. Today, Monique is driving opportunities to improve claim payment by designing and developing new prior auth and claim reconciliation products at Cohere Health.
Bruce Lim
Deputy Director, Audits and InvestigationsCalifornia Department of Health Care Services (DHCS)Bruce Lim serves as the Deputy Director, Audits and Investigations, for the California Department of Health Care Services (DHCS) and is the designated Program Integrity Director for Medi-Cal, California’s Medicaid program. Mr. Lim is a certified public accountant (CPA) with over 32 years of audit and financial management experience in both the private and public sectors. Past employers include Kenneth Leventhal and Company, CPAs (Ernst & Young Kenneth Leventhal Real Estate Group), Packard Bell NEC, and the California Department of Food and Agriculture.
Catherine Pesek Bird
Physician AdvisorLakeland Regional Health – FloridaBefore coming to LRH, Dr. Pesek practiced as an academic cardiologist at a large Big Ten medical center, leading teams of fellows, residents, and medical students. She provided direct patient care to cardiac patients, including transplant recipients and pregnant patients with either acquired or congenital heart disease. She worked on quality improvement programs in heart failure, sepsis, cardiac catherization, and medication adherence.
Prior to medical school, Dr. Pesek taught high school chemistry. She has written a book on understanding and determining end-of-life medical choices. She enjoys playing tennis and golf. She is a proud alumna of the University of Notre Dame.
Novelette Wallace, MPH, PMP, CSSBB
Head of Payment IntegrityJohns Hopkins HealthcareNovelette Wallace is a distinguished Payment Integrity Leader with a rich background spanning over 30 years in the healthcare industry. Her extensive experience includes leadership roles within payment integrity, where she has played pivotal roles in both payment integrity vendor organizations and health plans. Throughout her career, Novelette has demonstrated a remarkable ability to build and lead Payment Integrity departments from their inception. Her expertise has been instrumental in establishing robust processes and strategies to identify and recover inaccuracies in claims, contributing significantly to cost of care savings for health plans year after year.
Novelette has held key leadership positions with industry-leading organizations, including Performant Corp, United Healthcare, and Aetna (previously Coventry). In each role, she has consistently delivered results by optimizing payment integrity processes and driving operational excellence. Currently serving as the Assistant Vice President (AVP) of Payment Integrity for Johns Hopkins Health Plans, Novelette continues to bring her wealth of knowledge and leadership acumen to the forefront. Her dedication to achieving and surpassing cost of care savings goals exemplifies her commitment to advancing the financial health and efficiency of healthcare organizations.
With a proven track record of success and a comprehensive understanding of payment integrity within the healthcare landscape, Novelette Wallace stands as a respected leader in the industry, contributing significantly to the success of the organizations she serve
The Denial Playbook: Turning Rejections into Revenue (1 CEU)
- Learn proven tactics and strategies that the panelists have implemented within their organization to handle denials effectively and efficiently as they arise.
- Listen to our expert panel as they provide practical insights on building a robust denials management program.
- Discover the role technology plays in tracking, analyzing, and optimizing denial management workflows in our panelist's organizations.
Specialty Credits for: Core A – CPCO, CPMA
Session Topics:Revenue Cycle ManagementSpeaker(s):
Betye Ochoa
Director, Revenue Cycle RedesignNorthShore University HealthSystem
Ebrahim Barkoudah
System Chief & Regional Chief Medical & Quality OfficerBaystate Health
Brennan John
Director, Revenue CycleIntermountain Health10:15amEmerging Fraud Trends and Predictions for 2025
Uncover Emerging Threats: HCFS shares insights from working with leading health plans, highlighting rising fraud schemes and patterns they’ve detected across the industry.
Prepare for 2025: Gain actionable knowledge on upcoming FWA challenges and learn strategies to strengthen your fraud detection processes, ensuring your organization stays ahead in the evolving landscape.
Session Topics:Payment IntegritySponsor(s):Healthcare Fraud ShieldSpeaker(s):
Karen Weintraub
Executive Vice PresidentHEALTHCARE FRAUD SHIELDWith 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.
Driving Resiliency and Sustained Profitability Through Innovation and Technology
Macro trends & constraints to financial resiliency
Technology as a remedy: frameworks for evaluating & demystifying AI
Translating AI into real-world business value
Tangible examples of measured impact: Revenue + Cost/Labor
Speaker(s):
Bradford Kuntscher
Product SpecialistIodine Software12:00pmPayment Integrity Basics – Getting Started (0.5 CEU)
Specialty Credits for: Core A – CPCO, CPMA
Session Topics:Payment IntegritySpeaker(s):
Christopher Draven
Senior Director of Payment Integrity Analytics & AIHCSCChristopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.
Jodi Powell
Director of Payment IntegrityHCSCWith two decades of experience in the intricate realm of medical claims, I am currently serving as a Director within the Office of Payment Integrity, where my passion for precision and accountability fuels my work. My expertise lies in both pre- and post-claim payment accuracy, ensuring that our solutions not only meet regulatory standards but also uphold the highest level of integrity for patients and providers alike.
Throughout my career, I have developed a keen eye for detail and a strategic mindset, enabling me to identify inefficiencies and implement new solutions that enhance medical cost reduction. By fostering collaboration across teams, I have led initiatives that optimize processes and improve financial sustainability, ultimately benefiting all stakeholders involved.
I pride myself on my ability to transform challenges into opportunities for growth and innovation. My commitment to excellence and adherence to ethical standards has earned me a reputation as a trusted leader in the field. I am excited to connect with professionals who share a similar vision of advancing
Enhancing Medicare Part D Fraud, Waste & Abuse Program (FWA) (0.5 CEU)
Specialty Credits for: Core A – All specialties with exception of CIRCC, CPMS
Enhancing Medicare Part D Fraud, Waste & Abuse Program
Session Topics:Payment IntegritySpeaker(s):
Helen Liu, Pharm.D.
Health Plan LeaderIndependentHelen Liu, PharmD, brings 29 years of diverse pharmacy experience, blending clinical expertise, operational efficiency, technological innovation, and management across various healthcare settings.
Over the past four years, Helen has successfully led pharmacy operations at ATRIO Health Plans (Medicare), achieving significant milestones in PA/ST, FWA, MTM programs, resulting in over $4.5M in savings. She’s conducted formulary analyses to support actuary Medicare annual bid submissions, including IRA and M3P programs, collaborated with partners and the Pharmacy Benefit Manager (PBM) to identify cost-saving opportunities through formulary alternatives, biosimilars, and rebate strategies, and partnered in the RFP PBM selection process and resolved complex pharmacy-related issues through cross-departmental collaboration.
Before ATRIO, Helen spent seven years at Kaiser Permanente, where she served as Regional Assistant Director to implement hospitals Drug Use Management Program. Her efforts led to over $20 million in savings through inventory management, drug cost-saving initiatives, and the standardization of clinical content/practice guidelines.Increasing Capacity: How it Impacts Patient Access (0.5 CEU)
- Discover the four key capacity drivers that enhance patient access.
- Learn strategies to maximize capacity and access across clinics, groups, and organizations.
- Understand the metrics for measuring capacity and access and explore their interconnections.
Specialty Credits for: Core A – CPCO, CPMA
Session Topics:Revenue Cycle ManagementSpeaker(s):
Paul Schmitz
Executive Director, Patient AccessAdventHealth12:30pmExperimental Use of Implants and Biologics
Medical implants and biologics are a critical part of modern healthcare, but the FDA approval process for these devices is flawed creating provider and payor policy coverage confusion. Many implants are approved through the 510(k) pathway, which allows new devices to be cleared based on similarity to existing products and real world evidence data, rather than requiring clinical trials to demonstrate safety and efficacy.
This presentation will provide an in-depth look at the issues with the current FDA approval framework for implantable devices. We will examine case studies of problematic implants that have led to patient complications, and discuss the lack of reliable evidence required for many products. Attendees will learn about the criteria for reliable evidence that health plans should utilize to create coverage policies.
The session will address considerations for payors to protect members and ensure appropriate care, highlighting the role of payment integrity teams in identifying and validating implant charges.
By the end of this session, attendees will have a comprehensive understanding of the systemic issues with medical implant and biologics regulation, and practical approaches their organizations can implement to ensure appropriate utilization.
Learning Objectives/Key Takeaways of the Session (max 50 words, 2-3 bullet points):
- Understand the disconnect between the real world evidence required by the FDA versus reliable evidence necessary for approval.
- Explore the role of payment integrity in identifying overpayment related to these issues.
- Develop strategies to enhance payer policies and review processes to mitigate risks and manage biologics and implant coverage effectively
Session Topics:Payment IntegritySponsor(s):MedReviewSpeaker(s):
Ellen Catania
Sr. Director of Review OperationsMedReviewEllen is a registered nurse with extensive experience spanning clinical care and the health insurance industry, making her an expert in payment integrity and claims review. She has served as a clinical leader and consultant for payors and payment integrity companies. She excels in auditing high-value claims for third-party administrators and stop-loss carriers, while also providing clinical support to clients and addressing claim-related inquiries.
At MedReview, Ellen oversees the planning and development of Medicare and Medicaid hospital bill and DRG validation reviews and is also responsible for the oversight of the foreign and domestic nurse auditor teams conducting those reviews. An authority on Medicare and Medicaid policies, Ellen’s expertise also includes quality assurance oversight, peer review programs, and health plan contract interpretation.
The Datamining / COB Connection (How to Maximize Total Value to The Plan
Join us for an enlightening fireside chat that delves into the powerful relationship between data mining and Coordination of Benefits (COB) in the healthcare industry. As health plans strive for efficiency and cost-effectiveness, understanding how to integrate sophisticated data analytics into COB processes is crucial for maximizing total plan value.
- Understand the integration of data mining to enhance COB efficiency.
- Learn strategies for utilizing data insights to achieve cost savings and maximize plan value.
- Gain awareness of challenges and future trends in data-driven COB processes.
Session Topics:Payment IntegritySponsor(s):CarelonSpeaker(s):
Kyle Pankey
Sales & Growth LeaderCarelon SubrogationKyle 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.
Beth Franke
Staff Vice President, Payment Integrity Coordination of BenefitsElevance/AnthemBeth Franke started her career in the healthcare industry over 30 years ago. During that time, she has held management and leadership positions within large healthcare organizations such as Elevance Heath, Humana, Inc. and Kindred Healthcare and served as principal consultant for the Commonwealth of Kentucky, launching the state’s first self-funded health insurance model. She has also managed multi-discipline teams within special investigations, claims, enrollment and billing, corporate applications, mobile strategy, care management and enterprise project management office. Her current role as Staff Vice President has positioned her to oversee the Coordination of Benefits organization in Payment Integrity with over 500+ associates.
Beth has a BS in Mathematics and Computer Science from Centre College. She is a Project Management Professional (PMP), a Certified Professional Coder (CPC) and earned a Master Six Sigma Black Belt (MBB) certification from Villanova University. She also serves as a certified professional coach and was recognized as an Emerging Leader at Elevance Health.
Beth and her husband line in Louisville, KY and have five adult children. She enjoys hiking, biking and traveling with her family and is also active with several volunteer organizations, providing food, shelter, and other needed services for those less fortunate.
Jennifer Bellcour
Director Carelon Payment Integrity Solutions, Data MiningCarelonJennifer Bellcour is a seasoned leader in payment integrity, currently serving as the Director of Carelon Payment Integrity Solutions, Data Mining. With over 20 years at the company, she has been instrumental in advancing prepay data mining and claims anomaly detection initiatives. Known for her expertise, Jennifer excels at developing talent and building impactful teams to drive innovation. Her diverse background includes claims, billing, customer service, and training, and she is adept at partnering with global teams to support change management. Jennifer holds a Bachelor's degree from Southern New Hampshire University and a Master of Science in Management and Leadership (MSML) from Western Governors University.
Optimizing Hospital Authorization: Playing the Game Better to Prevent Denials and Ensure Timely Claims
Learn how to ensure all required information is submitted on time.
Maintain strong relationships with payers and proactively follow up on authorizations.
Utilize tools and workflows to streamline the process and reduce denials.
Speaker(s):
Ismet Sharich
Patient Access DirectorRiverside Healthcare01:00pmLunch Break & Structured One-to-One Networking
Session Topics:Medical Cost Containment02:30pmHarmonizing Tech and Talent: Revolutionizing COB Operations (0.5 CEU)
- In this session, we will delve into the practical applications of automation and data analytics, driving toward highest efficiency and effectiveness in your work, showcasing their benefits and limitations. We'll discuss real-life examples to illustrate the tasks AI can efficiently handle and the areas where human expertise remains crucial. Attendees will gain a comprehensive understanding of how these technologies can be leveraged within the sector, as well as insights on when to consider hiring or training staff to complement and enhance these tools.
- Learning Objectives: Understand how key automation, including AI, can increase accuracy, consistency and throughput in your operations - Explore how shifts in inventory prioritization can deliver higher results in other insurance identification
Specialty Credits for: Core A – CPCO, CPMA
Session Topics:Payment IntegritySpeaker(s):Beth Franke
Staff Vice President, Payment Integrity Coordination of BenefitsElevance/AnthemBeth Franke started her career in the healthcare industry over 30 years ago. During that time, she has held management and leadership positions within large healthcare organizations such as Elevance Heath, Humana, Inc. and Kindred Healthcare and served as principal consultant for the Commonwealth of Kentucky, launching the state’s first self-funded health insurance model. She has also managed multi-discipline teams within special investigations, claims, enrollment and billing, corporate applications, mobile strategy, care management and enterprise project management office. Her current role as Staff Vice President has positioned her to oversee the Coordination of Benefits organization in Payment Integrity with over 500+ associates.
Beth has a BS in Mathematics and Computer Science from Centre College. She is a Project Management Professional (PMP), a Certified Professional Coder (CPC) and earned a Master Six Sigma Black Belt (MBB) certification from Villanova University. She also serves as a certified professional coach and was recognized as an Emerging Leader at Elevance Health.
Beth and her husband line in Louisville, KY and have five adult children. She enjoys hiking, biking and traveling with her family and is also active with several volunteer organizations, providing food, shelter, and other needed services for those less fortunate.
Thomas Ricketts
Manager, Reporting and Data AnalysisElevance HealthThomas is an accomplished professional with 18 years of experience in the healthcare industry, specializing in the Coordination of Benefits. Currently serving as the Manager of Reporting and Data Analysis at Elevance/Carelon. His career is marked by a commitment to leveraging data-driven insights to enhance efficiencies and drive strategic decision-making.
A Journey through the Development and Deployment of a Pre-Payment Modelling System (0.5 CEU)
Showcasing one health plan’s process for creating a pre-payment system focused on reducing provider abrasion by paying more claims correctly the first time.
Specialty Credits for: Core A – CPCO, CPMA
Session Topics:Payment IntegritySpeaker(s):
Jordan Limperis
Data ScientistLA CareHighly motivated Data Scientist with a strong background in healthcare data and systems. Experienced in Inpatient Hospital and Laboratory Epic Systems, where I applied data-driven insights to improve clinical and operational efficiency. Currently, I am pursuing my career at L.A. Care, focusing leveraging advanced machine learning techniques to analyze noisy data, ensuring accuracy and efficiency in healthcare operations, particularly in payment integrity.
Edgar Dominguez
Claims Integrity Business ManagerLA CareHealthcare Operations expert with 20+ years of healthcare payer experience including 12+ years in Claims Administration with multiple fortune 200 companies. I’m currently focused on implementing payment integrity initiatives aimed at cost avoidance by the use of data analytics. I am a firm believer that data science is the wave of the future and will afford the healthcare industry with boundless opportunities to mitigate waste and reduce overall healthcare costs.
Structuring and negotiating offshore RCM partner relationships
- Key takeaways:
- Discover how cost arbitrage and staffing continuity make offshore services a viable option for many organizations. At the same time, understand the key challenges of security and quality concerns, along with actionable strategies to mitigate these risks effectively.
- Learn about market dynamics and service penetration across regions and categories
- Understand the pros and cons of various pricing models, critical questions to ask during negotiations, and common risks or pitfalls to avoid in contracting.
Session Topics:Revenue Cycle ManagementSponsor(s):Data Marshall Inc.Speaker(s):
Wess Pass
Chief Revenue OfficerData Marshall
Kimberly Collins Skinner, MBA, CHFP, CRCR
VP, Client ServicesData Marshall03:00pmAI & GenAI Benchmarks for Payment Integrity: Driving Measurable Outcomes
The future of payment integrity lies in the ability to harness Artificial Intelligence (AI) and Generative AI (GenAI) to improve outcomes. Yet, achieving measurable success requires more than just adopting technology—it demands the ability to set, track, and optimize benchmarks that align with your organization’s goals.
This session will dive into how healthcare payer executives can establish meaningful benchmarks to evaluate the impact of AI and GenAI on payment integrity. Learn how to define key performance indicators (KPIs) for fraud detection, cost savings, compliance improvements, and operational efficiencies. Explore strategies for tracking progress, identifying opportunities for refinement, and ensuring that your AI initiatives consistently deliver high-value results.
With a focus on real-world use cases and data-driven insights, attendees will walk away with actionable steps to enhance payment integrity outcomes through benchmark-driven approaches. Join us to discover how setting the right standards can help your organization maximize the potential of AI and GenAI, driving stronger financial and compliance performance.Sponsor(s):CodoxoSpeaker(s):
Musheer Ahmed, PhD
CEO & FounderCodoxoDr. Ahmed is the CEO and Founder of Codoxo. He founded Codoxo (formerly named FraudScope) to help make our healthcare system more affordable and effective. Codoxo’s Unified Cost Containment Platform uses AI to identify inaccurate payments earlier than traditional techniques, which helps ensure our scarce healthcare dollars go to real patient care. Dr. Ahmed developed this technology as a part of his Ph.D. dissertation at the Georgia Institute of Technology. A report by the JASON advisory group, the prestigious scientific advisory panel to the US government, reinforced that his doctoral research tackled some of the biggest challenges within the emerging health data infrastructure in the United States. Dr. Ahmed was honored to be included in the 40 Under 40 lists by Georgia Tech and the Atlanta Business Chronicle. Several media outlets have interviewed Dr. Ahmed about his work in reducing healthcare fraud, waste, abuse, and error. When he’s not eliminating payment inaccuracies, you’ll find him volunteering for various causes and spending time with his family.
Ric Baron, PhD
VP of Artificial IntelligenceCodoxoDr. Ric Baron is a healthcare technology strategist, AI analytics leader, and product
architect with over 20 years of experience in healthtech and insurtech. As Vice President of AI at Codoxo, he drives AI innovation and strategy, leading the development of advanced solutions for detecting fraud, waste, and abuse in healthcare—working toward the mission of making healthcare more affordable and accessible.Before joining Codoxo, Dr. Baron led computational healthcare research initiatives at world-renowned institutions, including the Howard Hughes Medical Institute, UC San Diego, and the Huntsman Cancer Institute at the University of Utah. He also served as a supercomputing advisor to The National Academies of Sciences, Engineering, and Medicine.
Dr. Baron has held senior leadership roles at companies such as Komodo Health, CVS Health, and Swiss Re, contributing his expertise in AI and data-driven healthcare solutions.
He earned his PhD in Computer-Aided Chemistry from ETH Zürich.Perfecting the Revenue Cycle: Tackling Denials with Data Integrity
- Learn to solve one of the most costly RCM Challenges - An open discussion regarding practical tools and insights to minimize costly errors and boost revenue.
- Discover technology enablers - How to determine if the value is attainable when choosing technology.
- Learn how to leverage all resources - The solution must include both your team and your technology.
Speaker(s):
Stacy Calvaruso
Vice President of Sales and Client DeliveryASP-RCM Solutions03:30pmRefreshment Break & One-to-One Structured Meetings
Session Topics:Medical Cost ContainmentWorkshop: The Impact of 2024 Price Transparency Rule on Health Plans
Price Transparency Rule Changes will have a profound effect on the accuracy and value of Hospital and Health Plan Price Transparency data. We will review those changes and the impact to health plans in terms of business intelligence, competitive positioning, and payment integrity use cases.
Session Topics:Payment IntegritySponsor(s):AMS Intelligent AnalyticsSpeaker(s):
John-Michael Loke
SVP, Health Plan Strategy & PartnershipsAMS04:45pmTransforming Payment Integrity: How AI and GenAI are Empowering Professionals to Work at the Top of Their License
Artificial Intelligence (AI) and generative AI have the transformative potential to revolutionize the payment integrity industry. These advanced digital capabilities are no longer visionary concepts but live practices that empower team members to work at the top of their licenses. By employing a human-in-the-loop approach to AI, payment integrity professionals can operate beyond gathering and collating data and focus on making critical decisions while staying at the forefront of these industry-changing innovations. This session will share real-world use cases on how these technologies are enabling transformative change – and ultimately driving improved outcomes – including how to access and interpret both structured and unstructured data, automate the distillation of critical insights from data into actionable information, and expose payment integrity vulnerabilities and accelerate mitigation initiatives.
Session Topics:Payment IntegritySponsor(s):EXLSpeaker(s):
William O'Neill
Vice President – Product Management, Payment IntegrityEXLNormalizing Love in Business
- Expand your perspective by exploring LOVE as a transformative business strategy.
- Discover how loving leadership fosters a culture of engaged and motivated employees.
- Reflect on strategies for normalizing love as an integral part of business practices.
Session Topics:Revenue Cycle ManagementSpeaker(s):
Cynthia Johnson
(former) Senior Director, Referral & Claims AdministrationKaiser Permanente05:15pmPayer-Provider Collaboration: Interoperability for Streamlined Administrative Operations
This session will bring together payers and providers to discuss the challenges and opportunities presented by healthcare mandates and electronic medical record systems. Participants will explore strategies for effective collaboration to improve patient care and reduce administrative burdens.
Session Topics:Payment IntegritySponsor(s):AMS Intelligent AnalyticsSpeaker(s):Novelette Wallace, MPH, PMP, CSSBB
Head of Payment IntegrityJohns Hopkins HealthcareNovelette Wallace is a distinguished Payment Integrity Leader with a rich background spanning over 30 years in the healthcare industry. Her extensive experience includes leadership roles within payment integrity, where she has played pivotal roles in both payment integrity vendor organizations and health plans. Throughout her career, Novelette has demonstrated a remarkable ability to build and lead Payment Integrity departments from their inception. Her expertise has been instrumental in establishing robust processes and strategies to identify and recover inaccuracies in claims, contributing significantly to cost of care savings for health plans year after year.
Novelette has held key leadership positions with industry-leading organizations, including Performant Corp, United Healthcare, and Aetna (previously Coventry). In each role, she has consistently delivered results by optimizing payment integrity processes and driving operational excellence. Currently serving as the Assistant Vice President (AVP) of Payment Integrity for Johns Hopkins Health Plans, Novelette continues to bring her wealth of knowledge and leadership acumen to the forefront. Her dedication to achieving and surpassing cost of care savings goals exemplifies her commitment to advancing the financial health and efficiency of healthcare organizations.
With a proven track record of success and a comprehensive understanding of payment integrity within the healthcare landscape, Novelette Wallace stands as a respected leader in the industry, contributing significantly to the success of the organizations she serve
Dave Cardelle
Chief Strategy OfficerAMS
Sandy Giangreco Brown
VP, Revenue Integrity & EducationSpire Orthopedic Partners
Donna Malone
Director Risk Capture, Population Health ManagementMass General Brigham
Corella Lumpkins
Manager of Coding, Compliance and Provider EducationLoudoun Medical Group P.C.Corella Lumpkins is the Manager of Coding, Compliance & Provider Education at Loudoun Medical Group (LMG) - one of the largest and most diverse physician-owned, multi-specialty Accountable Care Organizations in Northern Virginia/DC suburbs. As a subject matter expert, Corella has over 35 years of experience working in every area of the healthcare revenue cycle. Corella holds a bachelor’s degree and eleven certifications with an extensive background in auditing, billing, coding, implementing corporate compliance programs, CDI, education, denial and practice management. Prior to joining LMG, Corella has held leadership roles at Lifebridge, Medstar, Johns Hopkins and the University of Maryland health systems.
Corella is an author, adjunct faculty member and national speaker currently serving on both the AAPC National Advisory Board and Association of Clinical Documentation Integrity Specialists (ACDIS) Leadership Council. Corella works closely with providers in navigating patient-centric value-based care.
Accessing Success: Enhancing Patient Flow and Workforce Efficiency
- Key takeaway: Innovative Strategies for Improving Patient Access, Boosting Operational Efficiency, and Empowering Healthcare Teams
Session Topics:Revenue Cycle ManagementSpeaker(s):
Lisa Griffin, MBA, CCCM
Chief Consumer OfficerUniversity Hospitals05:45pmAssessing the Effectiveness of Revenue Cycle Training: The Trinity Health Journey (0.5 CEU)
- This presentation will provide a detailed Case Study review of Trinity Health’s Lean Daily Management Training Effectiveness Dashboard and the methodology used to measure Revenue Cycle knowledge transfer and proficiency.
- These tools and strategies are vendor agnostic and, in this example, will be applied to seventeen (17) different Health Information Systems (HIS) using the Kirkpatrick Model of Assessment and our experience with over 8,000 trainees.
- Content will provide a “deep dive” into what is possible in the assessment of Revenue Cycle training and, in addition, give a Journey Map for organizations to start where they are to begin evaluating their Revenue Cycle training effectiveness.
Specialty Credits for: Core B – CPPM
Session Topics:Revenue Cycle ManagementSpeaker(s):
Edward Thomas
Director, Enterprise Revenue Cycle Training & DeploymentTrinity Health (HQ Michigan)07:00pmSpeaker Dinner
Session Topics:Medical Cost Containment -
Thursday, 6 Feb, 202507:30am
Registration
Session Topics:Medical Cost Containment08:15amExclusive – Payment Integrity Savings PMPM Benchmarks
(45 min – 15 min presentation, 30 min open discussion)
No payment integrity savings benchmarks currently exist. Each health plan varies in payment integrity complexity – making it difficult to create industry standards. For the first time, HPRI has collaborated with payment integrity thought leaders to start to tackle this challenging but critical initiative. In this working session, hear how leaders are defining and calculating savings PMPMs across different programs, and share feedback to help health plans compare performance and optimize savings. Attendees will receive a post-event report with benchmarking insights.
Session Topics:Payment IntegritySpeaker(s):Dr. Priscilla Alfaro, MD, FAAP, CPC, CPMA, COC, CIC, CFE, CRC
VP Payment IntegrityBlue Cross NCDr. Priscilla Alfaro is a seasoned healthcare professional with extensive experience in executive medical management, fraud prevention, and healthcare analytics. A certified medical coder, fraud examiner, and auditor, she has a proven track record of improving healthcare efficiency and preventing fraud, waste, and abuse across various roles and affiliations, including the Texas HHS and Anthem.
Monique Pierce
Payment Solutions & OperationsCohere HealthMonique started her Payment Integrity career in COB at Oxford HealthPlans. After the merger with UnitedHealthcare, she led multiple teams and was responsible for creating innovative programs. Monique joined SCIO Health Analytics in 2014 and was responsible for system and process improvements before being promoted to VP of client engagement and business optimization In 2020, Monique joined start-up Devoted Health and created a full suite of programs from the ground up. Based on a passion for metrics and measuring performance, she centralized and standardized all programs reducing implementation time and maximizing savings. Today, Monique is driving opportunities to improve claim payment by designing and developing new prior auth and claim reconciliation products at Cohere Health.
Natalie Clayton
Head of Market IntelligenceKisaco ResearchRevenue Cycle Reimagined: Strategic Alignment Through Automation and Data-Driven Decisions
Session Topics:Revenue Cycle ManagementSpeaker(s):Howard Kung
Senior Director, Revenue CycleMayo Clinic09:00amAI Symposium & Fireside Chat
AI for PI (Christopher Draven, Crystal Son)
AI for Governance (Crystal Son, Simi Binning)
Revolutionizing Claims Processing: Responsible AI Strategies for Efficiency and Compliance (Fireside chat moderate by Dutch Noss)
Explore how responsible AI can revolutionize healthcare claims processing, payment integrity, and coordination of benefits. Learn actionable strategies for automating data workflows, improving claims adjudication, detecting fraud, enhancing compliance, and reducing member abrasion. This Fireside Chat will demonstrate how AI-driven insights streamline operations, reduce errors, and ensure financial and regulatory excellence.
Learning Objectives:
- Streamline Claims Processing: Leverage AI to automate workflows, improve accuracy, and reduce errors.
- Enhance Payment Integrity: Detect fraud, manage denials, and resolve overpayments efficiently.
- Optimize COB Management: Utilize AI for real-time eligibility checks, dynamic rule updates, and accurate payer sequencing.”
Session Topics:Payment IntegritySponsor(s):Alivia AnalyticsSpeaker(s):Moderator
Dutch Noss
Product & Strategy OfficerAlivia AnalyticsDutch Noss is a seasoned leader with over 25 years of expertise in Payment Integrity and Claims Processing, renowned for his pioneering approach to integrating responsible AI and machine learning into operational strategies. As Chief Product & Strategy Officer at Alivia Analytics, he drives innovations that improve accuracy within claims platforms. Dutch has held key leadership roles at various vendors and healthcare plans. A respected speaker at major healthcare conferences, he is recognized for blending deep industry knowledge with cutting-edge technology to shape the future of payment integrity.
Christopher Draven
Senior Director of Payment Integrity Analytics & AIHCSCChristopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.
Crystal Son
Executive Director of Enterprise Data Analytics SolutionsHCSCCrystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC), the largest customer-owned health insurer in the United States. HCSC provides access to care nationwide through Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas as well as through its broad portfolio of companies. Crystal has 20 years of experience in deriving intelligence from data and mobilizing teams to action.
At HCSC, she leads the Strategic Initiatives & Partnerships team, which leads key programs such as Payment Integrity, Responsible AI and AI Literacy and Workforce Readiness. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.
Prior to joining HCSC in October 2022, Crystal held several roles at previous organizations, including delivery of data science advisory services, management of healthcare and government customer portfolios, and the development and launch of several new products. She began her career in data as an epidemiologist, first for the City of New York, then with Memorial Sloan-Kettering Cancer Center but has called downtown Chicago home for the last 11 years.
Simi Binning
Responsible AI LeadHCSCSimi Binning is an accomplished healthcare professional with over a decade of experience in developing and executing successful strategies that drive business growth. Currently serving as a Responsible AI lead at HCSC, her focus is on AI governance and innovative problem solving.
Coding on Autopilot: Enhancing Efficiency Through Automation
Session Topics:Revenue Cycle ManagementSpeaker(s):
Lee Kupferman
Co-FounderPhare Health09:30amLooking at Risk from so Many Places (0.5 CEU)
- Gain a concise overview of the 5 OIG healthcare risk areas, including the False Claims Act, Anti-Kickback Statute, Civil and Monetary Penalties, Exclusions, and the Stark Law.
- Discover the areas commonly denied and at risk of violating the False Claims Act, including medical necessity of admissions and services, unbundling and improper coding and modifier assignment, double billing, billing for services not provided, upcoding, and billing non-covered services as provided.
- Walk away with resources available to identify what the OIG is targeting and internal resources that facilities can utilize to identify and mitigate hospital-specific risks.
- Learn about the factors to consider when determining the need to involve legal counsel.
Specialty Credits for: Core A – CPCO, CPMA, CIC, CRC
Session Topics:Revenue Cycle ManagementSpeaker(s):
Jill Sell-Kruse
Director, Compliance Risk & Oversight Ethics & ComplianceScionHealth10:00amKeeping Pace with Coding Compliance (0.5 CEU)
- Stay ahead of the latest OIG and CMS Coding Compliance regulations and learn how to proactively implement these updates in your departments or practices.
- Review key changes to the OIG Compliance guide and understand their potential impact on your operations.
- Discover proactive strategies to address compliance issues and stay informed on the most recent updates in the compliance landscape.
Specialty Credits for: Core A – CPCO, CPMA
Session Topics:Revenue Cycle ManagementSpeaker(s):Sandy Giangreco Brown
VP, Revenue Integrity & EducationSpire Orthopedic Partners10:30amRefreshment Break & One-to-One Structured Meetings
Session Topics:Medical Cost Containment11:45amCA Medicaid Program Integrity (0.5 CEU)
This session will focus on:
- California’s efforts to combat fraud, waste and abuse in Medi-Cal, California’s Medicaid program.
How California is exploiting available data and data sharing opportunities for purposes of Medicaid program integrity objectives.
A summary of program integrity best practices from the perspective of a Medicaid Program Integrity Director.
California’s future vision with regards to the use of data and data analytics to support its Medi-Cal fraud-control strategy.
Learning Objectives:
- Obtain program integrity best practices that can be leveraged by the participating entity.
Discover new ways to exploit data to identify and develop actionable leads.
Performance metrics and return on investment – ways to measure success.
Specialty Credits for: Core A – All specialty except CIRCC, CPMS, CPEDC
Session Topics:Payment IntegritySpeaker(s):Bruce Lim
Deputy Director, Audits and InvestigationsCalifornia Department of Health Care Services (DHCS)Bruce Lim serves as the Deputy Director, Audits and Investigations, for the California Department of Health Care Services (DHCS) and is the designated Program Integrity Director for Medi-Cal, California’s Medicaid program. Mr. Lim is a certified public accountant (CPA) with over 32 years of audit and financial management experience in both the private and public sectors. Past employers include Kenneth Leventhal and Company, CPAs (Ernst & Young Kenneth Leventhal Real Estate Group), Packard Bell NEC, and the California Department of Food and Agriculture.
Reading Between the Lines of Price Transparency
• Identify risk areas in chargemaster (CDM) pricing that are often overlooked.
• Describe ways to rationalize and defend pricing.
• Effectuate processes to stay current with price transparency regulations.Session Topics:Revenue Cycle ManagementSpeaker(s):
Sarah L. Goodman
President.CEOSLG, Inc.12:15pmA Payer’s Pathway to an Integrated Revenue Integrity & FWA Program
Session Topics:Payment IntegritySponsor(s):CoventBridgeSpeaker(s):
Anthony Baize
Inspector GeneralWisconsin Department of Health ServicesAnthony J. Baize is the Inspector General for the Wisconsin Department of Health Services. Baize took the position in early 2016 after eight years with Kentucky state government in the Kentucky Cabinet for Health and Family Services, serving as the Deputy Director of Audits and Investigations for the Office of Inspector General and the Director of Business Informatics with the Department of Behavioral Health, Developmental and Intellectual Disabilities.
Baize has served as the Region V representative for the National Association of Medicaid Program Integrity Directors and on the Advisory Board for the Centers for Medicare and Medicaid Services’ Medicaid Integrity Institute. He regularly speaks at national conferences on topics related to Medicaid Program Integrity.
Baize became a certified inspector general in 2022 after completing the Association of Inspectors General Institute. He is also a member of the Internation Association of Financial Crimes Investigators.
Baize was a civil rights consultant for nearly 20 years, serving on the Board of Directors for the National Fair Housing Alliance and the Lexington (KY) Fair Housing Council. Baize has given presentations on fair housing requirements across the United States, but especially in Kentucky, Indiana, Ohio and Tennessee. He has a master’s degree in public administration from Indiana State University, has been married for 29 years and has two daughters.
Ray Evans
Vice President of Healthcare SalesCoventBridge GroupRay Evans is a dynamic business development executive with extensive experience working within, and servicing healthcare organizations. He holds the position of Vice President of Healthcare Sales at CoventBridge Group where he utilizes his experience to share with the industry CoventBridge’s unmatched FWA investigative solutions. His goal is to work with health plans in protecting their organization from FWA through an experienced, flexible, and sensitive approach to minimizing provider abrasion, while still achieving organizational objectives.
Amanda Brown
Vice President - Revenue IntegrityCoventBridge GroupAmanda Brown is the Vice President of Revenue Integrity at CoventBridge Group where she provides expertise to her clients spanning Medicare Advantage, Medicare Part D, Medicaid, Marketplace, Commercial and FEHB products. She is a subject matter expert in the design and implementation of effective compliance, program integrity, risk, audit, vendor oversight, and ethics programs. Amanda has a keen ability to break down silos and bring organizational collaboration to facilitate compliance with policies, laws, regulations, and risk management.
Payment & Revenue Integrity Issues in Value-Based Care
Session Topics:Revenue Cycle ManagementSpeaker(s):
Frank Shipp
Executive DirectorJohns Hopkins MedicineFrank E. Shipp currently serves as Executive Director of the Johns Hopkins Clinical Alliance, the clinically integrated network of Johns Hopkins Medicine. The network includes over 3,000 providers, consisting of both employed and independent practices.
Frank transitioned to value-based care after 25 years of hospital-based operations experience in both community and academic health systems. During the past nine years, Frank has held executive positions in a Payor-Provider Organization in NYC and has built a highly successful CIN over a five-year period in Northern New Jersey. Frank speaks regular at national healthcare conferences regarding value-based care strategies and tactics.
Frank completed his MBA at Fairleigh Dickinson University, is a certified Fellow of the American College of Healthcare Executives and a trained Black Belt in Lean Six Sigma from Villanova University.
12:45pmJAWS: Financial Penetration with Oral Surgery Procedures
Maxillofacial surgeries and advancements with cutting edge technologies have evolved into an area of cosmetic and non-covered benefit abuse when billed to medical plans. Venture capitalists are disrupting the dental industry by purchasing large practices, promoting unnecessary procedures and opening Wellness Centers within dental practices. This presentation will identify the most common oral surgery procedures billed to medical plans, identify clinical schemes and misrepresentations being used to bypass edits. Holistic dental procedures will be addressed. This will allow medical review staff to gain an understanding into the complex language of dentistry to enhance investigations.
Session Topics:Payment IntegritySpeaker(s):Rae A. McIntee, DDS, MD, MBA, FACS, CPE
Medical Director Clinical Solutions (Supporting Payment Integrity & SIU)Louisiana BlueHave the Upper Hand: Negotiate Payer Contracts Like A Pro (0.5 CEU)
Explore insights and strategies needed to navigate contract negotiations with confidence and expertise, ensuring you secure the best terms for your organization.
Recognize resources for the rules governing various types of health plans and contracting entities.
Understand different reimbursement models, discuss techniques for preparing for
and conducting successful contract negotiations, and highlight common
challenges and how to overcome them.
Specialty Credits for: Core A – CPPM, CPCO
Session Topics:Revenue Cycle ManagementSpeaker(s):
Richelle Marting
Director, Managed Care ContractingNorth Kansas City Hospital, Meritas Health Corporation01:15pmLunch Break & Structured One-to-One Networking
Session Topics:Medical Cost Containment02:45pmThe Ongoing Threat of Telehealth Fraud
This presentation will delve into the latest trends and tactics employed by fraudsters, providing actionable insights to safeguard your organization. Attendees will gain a comprehensive understanding of the evolving threat landscape, learn to identify red flags and implement effective prevention strategies.
Session Topics:Payment IntegrityBeyond the Visit: Continuous Communication Strategies
Discover practical communication strategies to keep patients informed, engaged, and satisfied beyond their visit to the hospital.
- Explore the latest cutting-edge technology, such as automated messaging, AI-driven communication platforms, and personalized outreach strategies.
Session Topics:Revenue Cycle ManagementSpeaker(s):
Andrew Zurick
Medical Director Cardiac CT & MRI, Staff CardiologistAscension, St Thomas Heart
Michelle Myers
Director, Patient Financial ServicesBoulder CareLisa Griffin, MBA, CCCM
Chief Consumer OfficerUniversity Hospitals03:15pmTailoring Treatments and Curbing Costs with Precision Pharmacy
This session will explore how precision pharmacy can be used to optimize medication therapy for individual patients, leading to improved health outcomes while reducing overall healthcare costs.
Session Topics:Payment IntegritySpeaker(s):Collecting with Compassion: Improving Patient Financial Engagement (0.5 CEU)
Specialty Credits for: Core B- CPPMs
Session Topics:Revenue Cycle ManagementSpeaker(s):Becky Peters
Executive Director, Patient Access ServicesBanner Health03:45pmCombating the Opioid Crisis Through Pharmacy Payment Integrity
This session will explore how to identify and prevent opioid-related fraud within pharmacy claims, focusing on strategies to combat the opioid crisis while safeguarding healthcare resources.
Session Topics:Payment IntegritySpeaker(s):ModeratorHelen Liu, Pharm.D.
Health Plan LeaderIndependentHelen Liu, PharmD, brings 29 years of diverse pharmacy experience, blending clinical expertise, operational efficiency, technological innovation, and management across various healthcare settings.
Over the past four years, Helen has successfully led pharmacy operations at ATRIO Health Plans (Medicare), achieving significant milestones in PA/ST, FWA, MTM programs, resulting in over $4.5M in savings. She’s conducted formulary analyses to support actuary Medicare annual bid submissions, including IRA and M3P programs, collaborated with partners and the Pharmacy Benefit Manager (PBM) to identify cost-saving opportunities through formulary alternatives, biosimilars, and rebate strategies, and partnered in the RFP PBM selection process and resolved complex pharmacy-related issues through cross-departmental collaboration.
Before ATRIO, Helen spent seven years at Kaiser Permanente, where she served as Regional Assistant Director to implement hospitals Drug Use Management Program. Her efforts led to over $20 million in savings through inventory management, drug cost-saving initiatives, and the standardization of clinical content/practice guidelines.Anthony Baize
Inspector GeneralWisconsin Department of Health ServicesAnthony J. Baize is the Inspector General for the Wisconsin Department of Health Services. Baize took the position in early 2016 after eight years with Kentucky state government in the Kentucky Cabinet for Health and Family Services, serving as the Deputy Director of Audits and Investigations for the Office of Inspector General and the Director of Business Informatics with the Department of Behavioral Health, Developmental and Intellectual Disabilities.
Baize has served as the Region V representative for the National Association of Medicaid Program Integrity Directors and on the Advisory Board for the Centers for Medicare and Medicaid Services’ Medicaid Integrity Institute. He regularly speaks at national conferences on topics related to Medicaid Program Integrity.
Baize became a certified inspector general in 2022 after completing the Association of Inspectors General Institute. He is also a member of the Internation Association of Financial Crimes Investigators.
Baize was a civil rights consultant for nearly 20 years, serving on the Board of Directors for the National Fair Housing Alliance and the Lexington (KY) Fair Housing Council. Baize has given presentations on fair housing requirements across the United States, but especially in Kentucky, Indiana, Ohio and Tennessee. He has a master’s degree in public administration from Indiana State University, has been married for 29 years and has two daughters.
Eric Branson
Special AgentDepartment of Health and Human Services, Office of Inspector GeneralEric Branson is a special agent with the Department of Health and Human Services Office of Inspector General. Eric started investigating healthcare fraud in August 2011, spending time at both a Medicare and Medicaid contractor as well as working for the US Attorney's Office in the Middle District of Tennessee prior to becoming an agent. During that time, he has investigated fraud committed against both government and commercial insurance payors perpetrated by doctors, laboratories, pharmacies, home health agencies, durable medical equipment suppliers, and other healthcare providers. Eric graduated from Middle Tennessee State University with a Master's degree in Criminal Justice.
Creating Common Ground: Strategies for Payer-Provider Synergy
Explore strategies for fostering stronger partnerships and enhancing cooperation between payers and providers to achieve mutual goals.
Learn how successful collaboration can lead to better patient outcomes, more accurate reimbursements, and improved financial performance for both payers and providers.
Session Topics:Revenue Cycle ManagementSpeaker(s):Cynthia Johnson
(former) Senior Director, Referral & Claims AdministrationKaiser Permanente
Catherine Pesek Bird
Physician AdvisorLakeland Regional Health-FloridaDr. Priscilla Alfaro, MD, FAAP, CPC, CPMA, COC, CIC, CFE, CRC
VP Payment IntegrityBlue Cross NCDr. Priscilla Alfaro is a seasoned healthcare professional with extensive experience in executive medical management, fraud prevention, and healthcare analytics. A certified medical coder, fraud examiner, and auditor, she has a proven track record of improving healthcare efficiency and preventing fraud, waste, and abuse across various roles and affiliations, including the Texas HHS and Anthem.
Vanessa Moldovan, CRCR, CPC, CPB, CPMA, CPPM, CPC-I
Head of RCM StrategyMagicalMonique Pierce
Payment Solutions & OperationsCohere HealthMonique started her Payment Integrity career in COB at Oxford HealthPlans. After the merger with UnitedHealthcare, she led multiple teams and was responsible for creating innovative programs. Monique joined SCIO Health Analytics in 2014 and was responsible for system and process improvements before being promoted to VP of client engagement and business optimization In 2020, Monique joined start-up Devoted Health and created a full suite of programs from the ground up. Based on a passion for metrics and measuring performance, she centralized and standardized all programs reducing implementation time and maximizing savings. Today, Monique is driving opportunities to improve claim payment by designing and developing new prior auth and claim reconciliation products at Cohere Health.
06:00pm - 8:00pmPayer-Provider Party
Session Topics:Medical Cost Containment -
Friday, 7 Feb, 202508:30am
Registration
Session Topics:Medical Cost Containment09:30amAdopting and Integrating Diverse Technologies
- Discuss assessing and selecting the right technologies (e.g., EHRs, automation tools, AI, and analytics platforms) that align with an organization’s RCM needs and overall goals, considering factors like cost, scalability, and ease of integration.
- Explore the technical challenges of integrating diverse technologies into existing RCM workflows, including data interoperability and system compatibility.
- Address the human element of technology adoption, focusing on how to manage change within the organization, train staff effectively, and foster a culture of innovation to ensure successful implementation.
- Discuss how to measure new technologies and return on investment (ROI), including key metrics like reduced Days in AR, increased collection rates, improved patient satisfaction, and cost savings.
Session Topics:Revenue Cycle ManagementSpeaker(s):Brennan John
Director, Revenue CycleIntermountain HealthApplying AI and Data Analytics in Payment Integrity
In this interactive workshop, attendees will review and discuss their own experiences with AI, data analytics, and fraud prevention strategies covered during the conference. The session will focus on how these tools can be used for early issue detection and claims management, while also addressing new federal rules and fraud trends shared by regulatory experts. Walk away with actionable insights tailored to your organization’s challenges.
In collaboration with 4L Data Intelligence.
Session Topics:Payment IntegritySpeaker(s):Christopher Draven
Senior Director of Payment Integrity Analytics & AIHCSCChristopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.
Simi Binning
Responsible AI LeadHCSCSimi Binning is an accomplished healthcare professional with over a decade of experience in developing and executing successful strategies that drive business growth. Currently serving as a Responsible AI lead at HCSC, her focus is on AI governance and innovative problem solving.
Crystal Son
Executive Director of Enterprise Data Analytics SolutionsHCSCCrystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC), the largest customer-owned health insurer in the United States. HCSC provides access to care nationwide through Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas as well as through its broad portfolio of companies. Crystal has 20 years of experience in deriving intelligence from data and mobilizing teams to action.
At HCSC, she leads the Strategic Initiatives & Partnerships team, which leads key programs such as Payment Integrity, Responsible AI and AI Literacy and Workforce Readiness. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.
Prior to joining HCSC in October 2022, Crystal held several roles at previous organizations, including delivery of data science advisory services, management of healthcare and government customer portfolios, and the development and launch of several new products. She began her career in data as an epidemiologist, first for the City of New York, then with Memorial Sloan-Kettering Cancer Center but has called downtown Chicago home for the last 11 years.
Clay Wilemon
Chief Executive Officer4L Data Intelligence, Inc.Clay serves as CEO at 4L Data Intelligence™. He has launched over 500 new healthcare brands and holds patents in artificial intelligence and medical technologies. Clay is on the Board of Directors at Octane, a Southern California non-profit economic development organization that has helped hundreds of technology and med-tech companies get started. He a graduate of Vanderbilt University.
10:30Refreshment Break & One-to-One Structured Meetings
Session Topics:Medical Cost Containment11:00amThe Payer – Provider Synergy Problem
Exchange in conversations with other attendees to understand how enhanced data exchange can streamline workflows, reduce administrative burdens, and improve overall efficiency off the back off the payer-provider panel on Day 1. Review the role of interoperability and data sharing in improving fraud detection, claim accuracy, and cost management that were discussed throughout the event.
Session Topics:Medical Cost ContainmentSpeaker(s):Edward Marx
Chief Executive OfficerMarx AdvisoryThe youngest child of Holocaust survivors, Ed moved to the United States at age 10. At 16, he served as a medical clinic janitor where he discovered his healthcare calling. Ed took successive positions as combat medic, anesthesia tech, strategic planner and technology manager. He quickly learned how the convergence of clinical, business and digital saved lives. His passion ignited, he jumped feet first into technology and operations in the C-Suite of Cleveland Clinic, NYC Health & Hospitals, Texas Health Resources and University Hospitals.
Intermixed, Ed served the supplier side as well. He was CEO for consulting firm Divurgent, global CDO for Tech Mahindra Health & Life Sciences and CIO of the Advisory Board. Concurrently, he served 15 years as an Army combat engineer officer and combat medic. Today, Ed is focused on his own advisory practice.
Ed does a fair amount of speaking, writing and podcasting. He authored healthcare bestsellers including “Voices of Innovation” and “Healthcare Digital Transformation”. He is currently writing a book for Mayo Clinic on “Patient Experience” and “Voices of Innovation - Payers”. His podcast “DGTL Voices” is “Top 3%” globally. His Blog, CEO Unplugged, surpassed 1M views. Ed recently started a YouTube channel to expand his audience.
Most importantly, Ed is husband to Simran who holds a Doctor of Nursing (DNP). They love to dance and climb mountains. They have 5 grown children and 4 grandchildren. To stay fit, he is captain of TeamUSA Triathlon.
For more career information you can find me:
Twitter https://twitter.com/marxtango
LinkedIn https://www.linkedin.com/in/edwardmarx/
Website https://www.marxadvisory.com/
12:00pmGoodbye Lunch
Session Topics:Medical Cost Containment
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