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  • This session is designed for organizations without a payment integrity unit presently or a payment integrity unit in its infancy. This presentation will analyze when and how to evaluate pre-pay solutions versus post-pay solutions.
  • The presentation will first explore pre-pay options to enhance with your current claims adjudication system and how to implement a new claims editing system to interface with your current claims adjudication system. For post-pay options, presentation will discuss strategies in terms of first-pass, second-pass, and third-pass solutions. Discussion on post-pay contract negotiations will also be presented along with how to deal with provider and hospital pushback when implementing these new solutions.
  • A brief discussion regarding Coordination of Benefits (COB) will demonstrate that COB is more an enrolment issue versus a claims issue; asking the question: Should COB be considered in a payment integrity unit? The presentation will end with a focus on how to bring all these actions and issues into a new payment integrity unit.
  • Learning Objectives:
    • · Analyze differences between pre-pay and post-pay solutions.
    • · Compare different strategies and vendor solutions for first-pass, second-pass, and third-pass post-pay solutions.
    • · Examine methods to communicate with providers and hospitals to lessen major pushback when implementing these strategies.
    • · Discuss if COB should be a payment integrity issue.
    • · Evaluate different choices for starting a payment integrity unit.

Author:

Dr Michael Seavers

Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics
Harrisburg University

Dr. Michael Seavers is the Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics at Harrisburg University.  Dr. Seavers has a varied background in IT, business, and healthcare spanning many decades.  Dr. Seavers began as a programmer analyst at Shared Medical Systems and later at General Electric in their Aerospace Division.  Dr. Seavers then worked in IT management in the pick-pack-and-ship industry being employed at companies like Book-of-the-Month Club (Time Warner) and Hanover Direct during the .COM expansion.

As the .COM industry went bust, Dr. Seavers moved to the healthcare industry.  Dr. Seavers worked at Capital BlueCross for nearly two decades.  The first decade was as a Senior Manager in the IT department and the second decade as the Senior Director of Claims and later the Senior Director of Enrollment and Billing.  Dr. Seavers focus was automation of labor utilizing software robotics for healthcare. 

After a varied career background and various formal degrees, Dr. Seavers is very pleased to be teaching at Harrisburg University.

... read more

Dr Michael Seavers

Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics
Harrisburg University

Dr. Michael Seavers is the Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics at Harrisburg University.  Dr. Seavers has a varied background in IT, business, and healthcare spanning many decades.  Dr. Seavers began as a programmer analyst at Shared Medical Systems and later at General Electric in their Aerospace Division.  Dr. Seavers then worked in IT management in the pick-pack-and-ship industry being employed at companies like Book-of-the-Month Club (Time Warner) and Hanover Direct during the .COM expansion.

As the .COM industry went bust, Dr. Seavers moved to the healthcare industry.  Dr. Seavers worked at Capital BlueCross for nearly two decades.  The first decade was as a Senior Manager in the IT department and the second decade as the Senior Director of Claims and later the Senior Director of Enrollment and Billing.  Dr. Seavers focus was automation of labor utilizing software robotics for healthcare. 

After a varied career background and various formal degrees, Dr. Seavers is very pleased to be teaching at Harrisburg University.

VanillaPlus Issue 2 2024: iconectiv’s Mike O’Brien explains how verified identity will slam the door on fraud

Author:

Ankur Verma

Vice President
Everest Group

Ankur Verma is a member of the Business Process Services team and assists clients on topics related to optimizing business process service delivery models, with an emphasis on Healthcare (payers and providers) and Life Sciences. Ankur’s responsibilities include assisting in managing Everest Group’s Healthcare and Life Sciences Outsourcing subscription offerings and providing outsourcing advisory services to clients on an ad hoc basis.

Prior to joining Everest Group, Ankur was a Senior Analyst with The Smartcube. He holds a bachelor’s degree in technology from Netaji Subhas Institute of Technology, Delhi.

... read more

Ankur Verma

Vice President
Everest Group

Ankur Verma is a member of the Business Process Services team and assists clients on topics related to optimizing business process service delivery models, with an emphasis on Healthcare (payers and providers) and Life Sciences. Ankur’s responsibilities include assisting in managing Everest Group’s Healthcare and Life Sciences Outsourcing subscription offerings and providing outsourcing advisory services to clients on an ad hoc basis.

Prior to joining Everest Group, Ankur was a Senior Analyst with The Smartcube. He holds a bachelor’s degree in technology from Netaji Subhas Institute of Technology, Delhi.

IoT Now Magazine Q1 2024: The latest on IoT security, connectivity, transport, and utilities

The healthcare landscape is fraught with complexity and financial pitfalls and small-to-medium-sized health plans often find themselves vulnerable to inflated claims, hemorrhaging millions annually.

Payment integrity products like DRG Coding and Clinical Validation, Hospital Bill Audits, Data Mining, and more, can offer immediate reinforcement against dubious claims. But which products should be deployed, when should they be implemented, what are the best practices for their utilization, and how do you effectively evaluate their impact?

In this session, discover how merging clinical expertise with AI technology enhances payment integrity solutions and evaluate in-house, outsourced, or combined approaches based on reassignment and appeal overturn rates for optimal financial protection.

In a world where healthcare fraud runs rampant and financial losses mount, a strategic plan for payment integrity stands as a beacon of hope for small to medium-sized health plans, offering a formidable defense against the forces of fiscal depletion. This discussion will provide a framework for developing a strategic approach to financial stability.

Author:

Ted Pitynski

Chief Commercial Officer
MedReview

As the Chief Commercial Officer, Ted is responsible for the commercial growth of the company through his leadership of sales, marketing, and product management. Ted brings a wealth of knowledge from more than two decades of experience developing go-to-market strategies for selling complex healthcare solutions to payers, government agencies, benefit trusts and employers. Ted collaborates with sales teams, prospects, partners, and customers to capitalize on revenue-enhancing opportunities, setting new standards in the payment integrity industry.

Prior to joining MedReview, Ted transitioned from the finance sector to healthcare with a fervent commitment to revolutionizing the healthcare landscape. He was previously the Vice President of Self-Insured Solutions and Partnerships for ArmadaHealth, where he developed and executed the company’s distribution strategy. Ted also spent eight years as the Director of Health Plan Partnerships for HealthMedia, a wholly owned subsidiary of Johnson & Johnson.

... read more

Ted Pitynski

Chief Commercial Officer
MedReview

As the Chief Commercial Officer, Ted is responsible for the commercial growth of the company through his leadership of sales, marketing, and product management. Ted brings a wealth of knowledge from more than two decades of experience developing go-to-market strategies for selling complex healthcare solutions to payers, government agencies, benefit trusts and employers. Ted collaborates with sales teams, prospects, partners, and customers to capitalize on revenue-enhancing opportunities, setting new standards in the payment integrity industry.

Prior to joining MedReview, Ted transitioned from the finance sector to healthcare with a fervent commitment to revolutionizing the healthcare landscape. He was previously the Vice President of Self-Insured Solutions and Partnerships for ArmadaHealth, where he developed and executed the company’s distribution strategy. Ted also spent eight years as the Director of Health Plan Partnerships for HealthMedia, a wholly owned subsidiary of Johnson & Johnson.

History of Hospital at Home and Telehealth Services
Post Pandemic Growth and Barriers
Hospital at Home vs Home Health

Reduced Payer and Provider Costs
Developing Reimbursement Policies
Identifying Potential Fraud, Waste and Abuse

Lesson objectives:

- Overall knowledge of hospital at home and telehealth services
- How to create effective reimbursement policies for emerging healthcare services

Author:

Cereasa Horner

Director of Policy and Payment Integrity
CERIS

Cereasa Horner, MHA, is the Director of Policy and Payment Integrity for CERIS, a CorVel company. Cereasa has been an integral part of the CERIS team since 2017, and throughout her tenure, she has consistently displayed a rare combination of leadership, innovation, and a deep understanding of the healthcare industry. Her dedication to the mission and values of CERIS Health has been evident in every aspect of her work. She has developed CERIS’ internal payment integrity program and partnered with health plans to create and implement reimbursement policies related to claim audits. 

... read more

Cereasa Horner

Director of Policy and Payment Integrity
CERIS

Cereasa Horner, MHA, is the Director of Policy and Payment Integrity for CERIS, a CorVel company. Cereasa has been an integral part of the CERIS team since 2017, and throughout her tenure, she has consistently displayed a rare combination of leadership, innovation, and a deep understanding of the healthcare industry. Her dedication to the mission and values of CERIS Health has been evident in every aspect of her work. She has developed CERIS’ internal payment integrity program and partnered with health plans to create and implement reimbursement policies related to claim audits. 

Every payer can agree on one thing. There is fraud, waste, and abuse happening that they cannot see or see fast enough with the limitations of current claims data-centric technology stacks. One more technology in the stack doesn't solve the problem of not being able to see dynamic behaviors, relationships, and outliers that lead to over-payments on basic CMS edits as well as undetected complex fraud and collusion schemes. More claims data-centric technology is not the solution. Dynamic provider-centric risk detection technology coupled with continuously-credentialed provider integrity data is the solution for increased FWA detection and near real-time prevention. That's because stacks of claim data-centric technologies (even those using conventional artificial intelligence) will never see what providers are doing individually, in relationship with all other providers, and in relationship to all other claims on each-and-every claim submitted.

This session will focus on the benefits of a provider-centric FWA prevention approach powered by artificial intelligence that is dynamic and uses both supervised and unsupervised machine learning for detection beyond rules-based technologies. It will highlight strategies for FWA prevention at five points along the claims workflow including pre pre-payment, pre-payment, and post-payment positions. Fraud and SIU teams will be particularly interested in this combination of technologies to detect and automatically package fraud and collusion schemes you can’t see now or can’t see fast enough with the limitations of claim-centric approaches.

1. Understand the FWA detection limitations of claims data-centric approaches
2. Understand how a provider centric-approach such as Integr8 AI increases FWA detection and prevention
3. Understand the benefits of provider-centric FWA prevention pre pre-payment, pre-payment, and post-payment

Author:

Clay Wilemon

Chief Executive Officer
4L 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. 

... read more

Clay Wilemon

Chief Executive Officer
4L 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. 

Author:

Greg Lyon

Senior Fraud Advisor
4L Data Intelligence, Inc.

Greg is a recognized anti-fraud expert with experience in Financial Services and Healthcare Payments that includes serving as Director of Fraud Prevention at United Healthcare. His guiding principle is, “The best way to fight fraud is to prevent it.” Greg is a graduate of Colgate University and is a Certified Financial Planner.

... read more

Greg Lyon

Senior Fraud Advisor
4L Data Intelligence, Inc.

Greg is a recognized anti-fraud expert with experience in Financial Services and Healthcare Payments that includes serving as Director of Fraud Prevention at United Healthcare. His guiding principle is, “The best way to fight fraud is to prevent it.” Greg is a graduate of Colgate University and is a Certified Financial Planner.

  • This session delves into prevalent billing and coding errors encountered in healthcare reimbursement postpayment and prepayent processes, shedding light on their potential to result in overpayments for payers. Through case studies and practical examples, Healthcare Fraud Shield can showcase effective strategies for identifying common errors, such as incorrect billing of maternity care services.
  • This session will walk through:
      • Appropriate coding for delivery services 
      • Proper billing practices at it relates to antepartum and postpartum care 
      • How to detect patterns of inappropriate claim submissions

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. 

HPRI developed a first of it's kind, payment integrity industry survey, in partnership with the payers that are part of the HPRI network. The survey results are aggregated to provide powerful insights from all of the PI experts across the country. The aim of the survey was to evaluate current trends in the payment integrity market, explore the payer perspective of implications related to the complexity of the market, and gain insights from payers on the introduction of disruptive technologies enabling greater analytics for unstructured data, and
opportunities for future savings in the coming year. Join us for a review of the 2024 PI survey results to help drive your PI initiatives.

- Learn about the most prominent PI trends for 2024
- Explore new innovations and their impact on driving 2024 opportunites
- Leverage survey results to asses where your program and organization fall in relation to your peers in the industry

Author:

Dave Cardelle

Chief Strategy Officer
AMS
... read more

Dave Cardelle

Chief Strategy Officer
AMS