The Transformation to Real-Time Intelligence: How Clinical Data, AI, and New PI Capabilities are Accelerating the Pre-Pay Shift | Kisaco Research

The Transformation to Real-Time Intelligence: How Clinical Data, AI, and New PI Capabilities are Accelerating the Pre-Pay Shift

Clinical data is becoming the foundation that enables payment integrity to evolve from payment recovery to prevention, impacting payment accuracy and broader healthcare affordability goals. But this shift requires transforming how clinical data, AI, PI processes and people are aligned. Through a case study example, payment integrity and clinical data leaders from BCBS of South Carolina will discuss an innovative approach to using real-time clinical data to generate their own ‘claims’ to guide pre-payment reviews. Key topics will include:
  • Developing a roadmap for effective clinical data integration into pre-pay PI decision making and workflows
  • Reimagining the PI process – new capabilities, collaboration, and upscaling staff
  • Lessons learned while shifting from traditional post-pay operations and governance
Speaker(s): 

Author:

Karen S. Campbell

Senior Director, Payment Integrity, Payor Innovations Division
BlueCross BlueShield of South Carolina

Karen Campbell is Senior Director for Payment Integrity at BlueCross BlueShield of South Carolina. She has been part of Payment Integrity team since early inception and helped develop core team capabilities from data mining to policy application and clinical support. Her recent focus has been on solution deployment that expands system edits, provider education and increases clinical claim reviews both pre-pay and post-pay.  She has worked closely with Operations, Decision Support and Medical Affairs to help take new policies, technology and edits from inception to deployment throughout the organization.

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Karen S. Campbell

Senior Director, Payment Integrity, Payor Innovations Division
BlueCross BlueShield of South Carolina

Karen Campbell is Senior Director for Payment Integrity at BlueCross BlueShield of South Carolina. She has been part of Payment Integrity team since early inception and helped develop core team capabilities from data mining to policy application and clinical support. Her recent focus has been on solution deployment that expands system edits, provider education and increases clinical claim reviews both pre-pay and post-pay.  She has worked closely with Operations, Decision Support and Medical Affairs to help take new policies, technology and edits from inception to deployment throughout the organization.

Author:

Autumne Smith

Director, Connected Health Services
BlueCross BlueShield of South Carolina
Autumne Smith is the Director of Connected Health Services at BlueCross BlueShield of South Carolina, where she leads enterprise initiatives focused on interoperability, clinical data exchange, regulatory readiness, and connected health innovation. With more than 10 years of experience across health care data, technology, governance, and operations, Autumne brings together business strategy, technical execution, and compliance rigor to advance how health information is exchanged, governed, and used to improve outcomes.
Autumne earned her Master’s in Health Information Technology from the University of South Carolina and her Bachelor of Art in Psychology from Winthrop University.
... read more

Autumne Smith

Director, Connected Health Services
BlueCross BlueShield of South Carolina
Autumne Smith is the Director of Connected Health Services at BlueCross BlueShield of South Carolina, where she leads enterprise initiatives focused on interoperability, clinical data exchange, regulatory readiness, and connected health innovation. With more than 10 years of experience across health care data, technology, governance, and operations, Autumne brings together business strategy, technical execution, and compliance rigor to advance how health information is exchanged, governed, and used to improve outcomes.
Autumne earned her Master’s in Health Information Technology from the University of South Carolina and her Bachelor of Art in Psychology from Winthrop University.
Time: 
12:45pm
Agenda Track No.: 
Track 2
Session Type: 
Panel
Force Inline Description: 
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