Richelle Marting
Director, Managed Care Contracting
North Kansas City Hospital, Meritas Health Corporation
Description: CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM
Over the last few years, there have been many cases of hospitals receiving inappropriate reimbursement for medical procedures. This session will focus on the procedures associated with these cases, including diagnostic and therapeutic procedures for access sites of dialysis patients, peripheral vascular patients and a variety of surgical procedures. We will explore these cases and discuss the characteristics and scenarios that lead to inappropriate reimbursement.
Learning Objectives:
Through the case study approach, examine specific types of hospital procedures that have been associated with inappropriate reimbursement
Explore methods for preventing, detecting and correcting errors leading to inappropriate reimbursement for these procedures.
CJ Wolf
Professor and Asst. Program Director
Brigham Young University-Idaho
AI is rapidly gaining traction across the healthcare space, driven by growing interest in generative AI, which can create content like text, images, and code. AI adoption, which hovered around 50 percent over the past six years, has surged to 72 percent this year. Within payment integrity, AI can help health plans escape from decades of legacy applications and outsourced high contingency fee vendors that have no incentive to automate/innovate.
Listen to industry experts discuss how to start implementing AI today and to create a balanced approach to AI adoption, one that embraces innovation while carefully managing risks.
Learning Objectives:
- Initiating AI Implementation in Healthcare: Understand the practical steps and strategies for beginning AI implementation within payment integrity, moving away from outdated systems and reliance on vendors with limited incentives for innovation.
- Leveraging AI for Payment Integrity: Learn what payment integrity use cases are ready for AI deployment helping reduce dependency on legacy applications, ultimately improving efficiency and reducing costs for health plans.
- Balancing AI Innovation with Risk Management: Explore how to adopt AI in a way that maximizes innovation while carefully managing potential risks.
Prasanna Ganesan
CEO
Machinify
Brandon Shelton
Senior Director, Advanced Analytics Lab
L.A. Care
Brandon Shelton is the Senior Director of the Advanced Analytics Lab at L.A. Care, the country's largest public-option health plan, where he leads teams of Data Scientists and Data Analysts to support the health plan's various enterprise domains with machine learning solutions, program impact assessments, and business intelligence deliverables. The team's contributions towards Payment Integrity savings consistently exceeds $20M per year.
Machinify
Website: https://www.machinify.com/
Machinify is transforming healthcare administration with AI. At the core of Machinify is an AI cloud platform that digests and unifies policies, guidelines, and data transforming healthcare administration. Machinify's platform and services power revolutionary applications that interoperate for seamless execution across the healthcare claims lifecycle:
- Machinify Audit: End-to-end system utilizing GenAI and large language models (LLMs) to perform automated coding validation of complex claims.
- Machinify Pay: Software that enforces coding and payment policies against claims and prices claims accurately.
Session Overview
- With rising medical utilization, diminished prior auth, and greater inflationary pressures, health plans now more than ever must adopt innovation to prevent spend on fraud, waste and abuse (FWA). FWA reduction offers a huge opportunity to improve spend and member outcomes – by reducing unnecessary spend and aligning providers with best practices to avoid waste and harm. With new advances in FWA detection, plans can now improve their ability to reduce payment on FWA claims with tools that analyze patient data and provider patterns to precisely identify the services that might be wasteful or abusive.
During this case study, ATRIO Health Plans and Health at Scale will discuss the impact seen from implementing smart, context-aware FWA flagging into pre-adjudication along with a targeted provider education campaign and how the team was able to successfully drive down medical spend by 1.8% in the first year.
Learning Objectives/Key Takeaways of the Session
- Learn how ATRIO Health Plans crafted an innovative new FWA detection program and the factors that led to their substantial spend improvement
- See how new advances in FWA detection improve upon traditional systems by considering real-time context about individual patient history, provider patterns, and medical guidelines to determine if a service is appropriate
- Learn how FWA flagging in pre-adjudication can be supplemented with a targeted provider education program to align provider practices with best standards of care
Jennifer Callahan
COO
ATRIO Health Plans
Jen Callahan is the President and Chief Operating Officer of ATRIO Health Plans. For over 20 years, Jen has established herself as a trusted thought leader who helped shape the managed care industry with her innovative ideas and expertise. Jen has dedicated her career almost exclusively to Medicare Advantage and Medicare Supplement programs.
Prior to joining ATRIO, she co-founded a field management organization, Keen Insurance Services, Inc. to create a provider-centric Medicare focused sales and distribution organization from the ground up. Prior to that, she held the position of Vice President, Medicare Product at Aetna, a CVS Health company where she oversaw the product development and implementation of Aetna’s entire Medicare portfolio supporting record breaking growth for the Medicare organization. Throughout her career, Jen has also held various leadership positions at Healthfirst and Elevance.
Jen received her Bachelor of Science degree from Fordham University and MBA from North Carolina State University. Jen currently resides in Waxhaw, a suburb of Charlotte, North Carolina with her husband, their three kids, tuxedo cat, Vivi and golden retriever puppy, Steve.
Zeeshan Syed
Chief Executive Officer
Health at Scale
Zeeshan serves as Health at Scale’s CEO and was a Clinical Associate Professor at Stanford Medicine and an Associate Professor with Tenure in Computer Science at the University of Michigan. He was previously part of the early stage team that launched Google[X] Life Sciences (now Verily). Zeeshan is a recipient of multiple awards including an NSF CAREER award and holds a PhD from MIT EECS and Harvard Medical School in Computer Science and Biomedical Engineering, and MEng and SB degrees in EECS from MIT.
Health at Scale, Corp.
Website: https://www.healthatscale.com/
Health at Scale is advancing the next-generation of fraud, waste and abuse detection through real-time context-aware intelligence that allows health plans and third-party administrators to detect and act on inappropriate payments across pre-adjudication and post-pay. Founded by artificial intelligence and clinical faculty from MIT, Harvard, Stanford and U-Michigan, the company offers software solutions and fully-managed technology-enabled services to contain medical costs and reduce administrative burden. Health at Scale’s customers include some of the largest payers and TPAs in the U.S.; with the company’s breakthrough Precision FWA Detection™ technology consistently demonstrating 1-2% incremental reduction in total medical spend in large prospective deployments for Medicare Advantage and Commercially-Insured populations.
For more information please visit healthatscale.com.
Zeeshan Syed
Chief Executive Officer
Health at Scale
Zeeshan serves as Health at Scale’s CEO and was a Clinical Associate Professor at Stanford Medicine and an Associate Professor with Tenure in Computer Science at the University of Michigan. He was previously part of the early stage team that launched Google[X] Life Sciences (now Verily). Zeeshan is a recipient of multiple awards including an NSF CAREER award and holds a PhD from MIT EECS and Harvard Medical School in Computer Science and Biomedical Engineering, and MEng and SB degrees in EECS from MIT.
Jennifer Callahan
COO
ATRIO Health Plans
Jen Callahan is the President and Chief Operating Officer of ATRIO Health Plans. For over 20 years, Jen has established herself as a trusted thought leader who helped shape the managed care industry with her innovative ideas and expertise. Jen has dedicated her career almost exclusively to Medicare Advantage and Medicare Supplement programs.
Prior to joining ATRIO, she co-founded a field management organization, Keen Insurance Services, Inc. to create a provider-centric Medicare focused sales and distribution organization from the ground up. Prior to that, she held the position of Vice President, Medicare Product at Aetna, a CVS Health company where she oversaw the product development and implementation of Aetna’s entire Medicare portfolio supporting record breaking growth for the Medicare organization. Throughout her career, Jen has also held various leadership positions at Healthfirst and Elevance.
Jen received her Bachelor of Science degree from Fordham University and MBA from North Carolina State University. Jen currently resides in Waxhaw, a suburb of Charlotte, North Carolina with her husband, their three kids, tuxedo cat, Vivi and golden retriever puppy, Steve.
Angela Zigler
Special Agent
Food and Drug Administration Office of Criminal Investigation