• 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.

• Gain insights into the current state of the RCM industry and understand the key challenges healthcare organizations face. 
• Identify strategic priorities for enhancing financial performance and optimizing the revenue cycle. 
• Explore the impact of adopting cutting-edge technologies and tools to streamline revenue cycle management processes, reduce costs, and improve overall profitability.

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

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.

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.   

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.