| Page 797 | Kisaco Research

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

Payment Integrity
Revenue Integrity

Author:

Andrea Beatrice

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

Andrea Beatrice

Director of Payment Integrity and FWA
Health New England

Author:

Monique Pierce

Payment Solutions & Operations
Cohere Health

Monique 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.  

... read more

Monique Pierce

Payment Solutions & Operations
Cohere Health

Monique 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.  

- Coordinating the efforts of credentialing/enrollment, audits, investigations (SIUs), provider sanctions, and
policy
- Very few insurance payers have all those groups working together in a coordinated effort to reduce fraud,
increase revenue, and render excellent customer service to enrolled health care providers.

Payment Integrity

Author:

Dale Carr

Director
Missouri Medicaid Audit and Compliance (MMAC)

Dale Carr currently serves as Director of the Missouri Medicaid Audit & Compliance (MMAC) unit, which
has overall responsibility for Medicaid program integrity efforts. Dale has worked for the State of
Missouri since 2011. Director Carr was previously a Police Officer in Fallon, NV; an Investigator for the
U.S. Office of Special Counsel; and a Supervisory Special Agent with the Coast Guard Investigative
Service. Dale holds a Bachelor’s degree in Administration of Criminal Justice and is a graduate of the

158th Session of the FBI National Academy.

... read more

Dale Carr

Director
Missouri Medicaid Audit and Compliance (MMAC)

Dale Carr currently serves as Director of the Missouri Medicaid Audit & Compliance (MMAC) unit, which
has overall responsibility for Medicaid program integrity efforts. Dale has worked for the State of
Missouri since 2011. Director Carr was previously a Police Officer in Fallon, NV; an Investigator for the
U.S. Office of Special Counsel; and a Supervisory Special Agent with the Coast Guard Investigative
Service. Dale holds a Bachelor’s degree in Administration of Criminal Justice and is a graduate of the

158th Session of the FBI National Academy.

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

Author:

Karen Weintraub

Executive Vice President
HEALTHCARE FRAUD SHIELD

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

... read more

Karen Weintraub

Executive Vice President
HEALTHCARE FRAUD SHIELD

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

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

Payment Integrity

Author:

Jennifer Dupee

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

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

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

... read more

Jennifer Dupee

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

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

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

- Implementing a streamlined claims process to prevent missing information and incorrect coding, and
tracking patterns claim denials to mitigate future issues
- Highlighting causal factors such as front-end errors related to benefit information, coverage details, and
missing or invalid claims data
- Discussing the value of automated denial management systems as a means to reduce administrative
burden

Revenue Integrity

- How does Claim Audit fit into the overall savings goals from PI?
- Archaeology amongst savings drivers? High $ treasures?
- Claim Audit Digs & Research – driving process improvement, not just savings.
- Do underpayments matter?
- How to keep finding treasure:
- Partnering with other departments as a true “Partner” not an “Auditor.”
- It will all be in a museum (creating reference materials).

Payment Integrity

Author:

Tom Martin

AVP, Payment Integrity
Molina Healthcare
... read more

Tom Martin

AVP, Payment Integrity
Molina Healthcare

- Using an AI-first approach to enhance transparency and accuracy throughout the payment continuum

Payment Integrity

Author:

Mike Spellman

Senior Director, Consulting & Solution Design
Lyric
... read more

Mike Spellman

Senior Director, Consulting & Solution Design
Lyric