Animal Health Institute
- Update on new CPT codes and "old" CPT codes and how to document
- Learning Objectives:
- Learn about new CPT codes coming January 2025
- Understand the documentation required for the codes
David Flannery
Director of Telegenetics and Digital Genetics
Cleveland Clinic
David Flannery is a "pioneer" in telemedicine, having started telegenetics clinic in 1995 in Georgia. He’s currently the Director of Telegenetics and Digital Genetics at Cleveland Clinic. He has expertise with ICD-10 coding and CPT codes. He oversaw the revenue cycle management for the 300+ physician practice group at the Medical College of Georgia. He served on the American Medical Association's Digital Medicine Payment Advisory Group, developing new CPT codes for telemedicine and digital medicine.
9: 30 – 11 – AI Symposium
9:30 – Introduction
9:30 – 10:30 – The Future of AI in Healthcare Payments (Panel)
Panellists: Monique Pierce, Conor McCauley, Frank Shipp, Tom Everett
Moderator: David Ott, CGI
10:30 – 10:50 – Vendor Demos of AI Capabilities
10:50 – 11:00 – Optimizing AI in Healthcare Payment Integrity
Speaker: Natalie Clayton, Private Consultant
Monique Pierce
Payment Solutions & Operations
Cohere 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.
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.
Frank Shipp
Executive Director
Johns Hopkins Medicine
Frank 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.
Thomas Everett
Subject Matter
Expert Independent
David Ott
Director Consulting Payment Integrity
CGI
David Ott has over 28 years of experience in the healthcare and financial services industries. David has provided leadership and direction to department leaders and teams that support a variety of functions, including business development, payment integrity, claims processing, global project management and quality practices.
CGI
Website: https://www.cgi.com/us/en-us
Founded in 1976, CGI is among the largest IT and business consulting services firms in the world. We are insights-driven and outcomes-based to help accelerate returns on your investments. Across hundreds of locations worldwide, we provide comprehensive, scalable and sustainable IT and business consulting services that are informed globally and delivered locally.
This presentation will explore the various factors impacting claims trends, including utilization rates, unit costs, provider billing issues, claim payment mishaps, and inaccuracies in loading member benefits and provider rates. A key strategy to address these issues is the implementation of a robust payment integrity process. By combining the efforts of internal staff and expert vendors, payment integrity processes can significantly influence claims trends, thereby enhancing the overall profitability of health plans.
We will delve into specific examples to assess whether payment integrity efforts have successfully bent the claims trends or maintained them at a steady level. Additionally, the presentation will cover effective communication strategies with actuaries to ensure accurate data analysis and reporting. This dialogue is crucial for aligning strategic objectives and operational tactics with the actuarial insights necessary for informed decision-making in health plan management.
- Understanding of how to assess changes in claim trends
- How to effectively communicate with actuary teams to ensure accurate data analysis and reporting
Harold Davis
VP, Product Growth
Rialtic
Rialtic
Website: https://www.rialtic.io/
Rialtic is a modern healthcare technology platform focused on payment accuracy. Built by a team of seasoned industry veterans, Rialtic addresses the most important areas of the payment process. Payment policies are highly configurable and customizable: insurers can edit or build their own bespoke policies, while providers can analyze potential reimbursement levels. Robust analytics features across claims, lines of business, payments, and policies provides insightful business intelligence to users. By continuously sourcing, ingesting, and structuring healthcare payment policy documents and data, customers can confidently make up-to-date decisions. Keeping security and compliance top of mind, Rialtic empowers healthcare organizations to work off the same platform with rigorous security controls, a standard in enterprise software.
Healthcare payors and providers, as well as employers, are recognizing the importance of value-based care. Pressure to reduce avoidable cost and utilization, coupled with the demand to improve quality outcomes has caused payment models to move from fee-for-service to fee-for value. To succeed in this new paradigm, payors must collaborate with other stakeholders to design and implement value-based care models that meaningful and sustainable. These models must address the needs of all stakeholders, including the payors, providers, employers and the patients.
Learning Objectives:
- Synergistic opportunities for payors and providers to establish value-based programs
- Efficient allocation of resources when implementing value-based care
- Mitigating risk of downside value-based payment models
- Responding to disruptors
Frank Shipp
Executive Director
Johns Hopkins Medicine
Frank 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.