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Engage in focused, small-group discussions where payers and providers connect over specific topics, share perspectives, and explore solutions from both sides—offering a balanced, holistic view of key challenges and opportunities.
  • Price Transparency 4 Years In: Navigating Compliance, Challenges, and Opportunities for Providers and Payers
    Join us for a dynamic roundtable at the Healthcare Payment and Revenue Integrity Congress, where providers and payers will explore the impact of price transparency. Led by Dave Cardelle (SIIA Price Transparency Committee), the session will examine key challenges and strategies around the CMS Final Rule on Hospital Price Transparency and TiC MRFs, four years on. Discussion topics include compliance, penalties, costs, rate setting, contract negotiations, and using transparency data for analysis. Don’t miss this chance to share insights and shape the future of price transparency.
    Dave Cardelle, Chief Strategy Officer, AMS
  • Payment Integrity 101
    Join us for Payment Integrity 101 at the Healthcare Payment and Revenue Integrity Congress, a foundational session designed for those new to or expanding their role in payment integrity. This session will break down the key components of payment integrity, from pre-pay to post-pay strategies, common fraud, waste, and abuse (FWA) schemes, to how plans and providers can align on reducing improper payments. Whether you're building a team, refining your approach, or just starting out, this session offers a practical roadmap and terminology primer to help you navigate the space with confidence.
    Simi Binning, Responsible AI Lead, HCSC
    Charlie Jensen, Head of Payment Integrity Strategy,  Blue Cross Blue Shield, Illinois

  • Provider Contracts Uncovered: From Fine Print to Financial Power

    Contracts are more than legal fine print. They decide whether your organization thrives or just survives. In this session, we’ll pull back the curtain on contract language, expose common traps that drain revenue, and share negotiation tactics that actually move the needle. Expect real talk, practical tips, and a fresh look at how providers can flip contracts into cost-containing, revenue-protecting assets.

    Quick-Hit Takeaways
    Spot the traps: Know the clauses that cost you most.
    Negotiate smarter: Tactics payers don’t want you to know.
    Stay compliant: Align terms with today’s rules.
    Think strategic: Make every contract work for your bottom line.

    Maya Turner, Executive Managing Director, Turner Expert Consulting Services, LLC

Medical Cost Containment

Author:

Maya Turner

Owner/Executive Managing Director
Turner Expert Consulting
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Maya Turner

Owner/Executive Managing Director
Turner Expert Consulting

Author:

Dave Cardelle

Chief Strategy Officer
AMS
... read more

Dave Cardelle

Chief Strategy Officer
AMS

Author:

Charlie Jensen

Head of Payment Integrity Strategy
Blue Cross Blue Shield, Illinois
... read more

Charlie Jensen

Head of Payment Integrity Strategy
Blue Cross Blue Shield, Illinois

Author:

Simi Binning

Responsible AI Lead
HCSC

Simi Binning is an accomplished healthcare professional with over a decade of experience in developing and executing successful strategies that drive business growth. Currently serving as a Responsible AI lead at HCSC, her focus is on AI governance and innovative problem solving.

... read more

Simi Binning

Responsible AI Lead
HCSC

Simi Binning is an accomplished healthcare professional with over a decade of experience in developing and executing successful strategies that drive business growth. Currently serving as a Responsible AI lead at HCSC, her focus is on AI governance and innovative problem solving.

Denial management isn’t just about fighting back—it’s about understanding why denials happen and fixing the root causes upstream. This session will focus on how hospitals and health systems can use audit findings and denial data to identify coding gaps, documentation weaknesses, and process breakdowns that lead to preventable denials. Learn how to close these gaps through stronger internal collaboration across revenue cycle, coding, and clinical teams, while also using data-driven insights to foster more productive payer relationships.


Learning Objectives:

  • Learn how to analyze denial patterns and audit results to uncover documentation, coding, and process issues—enabling proactive prevention rather than reactive rework.
  • Discover best practices for improving internal workflows, fostering collaboration between clinical and revenue cycle teams, and ensuring that claims reflect accurate, defensible coding and clear clinical intent.
Revenue Cycle Management

Author:

Betye Ochoa

Director, Revenue Cycle Redesign
NorthShore University HealthSystem
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Betye Ochoa

Director, Revenue Cycle Redesign
NorthShore University HealthSystem

Author:

Kimberly D Conner

Subject Matter Expert
Independent
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Kimberly D Conner

Subject Matter Expert
Independent
Payment Integrity

Author:

Matt Perryman

Chief Analytics & Insight Officer
Alivia Analytics
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Matt Perryman

Chief Analytics & Insight Officer
Alivia Analytics

Author:

Scott Hirschbrunner

Director of Payment Integrity
Nebraska Blue

Scott brings a wealth of experience, with a 26-year background in PI leadership at CMS, Optum, and Blue Cross & Blue Shield of Kansas City. He currently is the Director of Payment Integrity at Blue Cross Blue Shield of Nebraska.  His functional areas of responsibility include SIU, Recovery, Bill-Audit, Claim Editing, COB, W/C, Subrogation, DRG Audit, Data Mining and Credit Balance Recovery.  Scott’s goals are strengthening management of PI vendor performance and contracts, seeking opportunities for generating revenue and setting of targets using national benchmark data.  He holds a Bachelor of Science in Accounting with a minor in Management and Communications and is well-versed in both commercial and government lines of business.  Scott is married for 16 years with two boys and two girls. He enjoys being outdoors, doing yard work, taking walks, coaching girls’ softball, giving blood, and volunteering.

... read more

Scott Hirschbrunner

Director of Payment Integrity
Nebraska Blue

Scott brings a wealth of experience, with a 26-year background in PI leadership at CMS, Optum, and Blue Cross & Blue Shield of Kansas City. He currently is the Director of Payment Integrity at Blue Cross Blue Shield of Nebraska.  His functional areas of responsibility include SIU, Recovery, Bill-Audit, Claim Editing, COB, W/C, Subrogation, DRG Audit, Data Mining and Credit Balance Recovery.  Scott’s goals are strengthening management of PI vendor performance and contracts, seeking opportunities for generating revenue and setting of targets using national benchmark data.  He holds a Bachelor of Science in Accounting with a minor in Management and Communications and is well-versed in both commercial and government lines of business.  Scott is married for 16 years with two boys and two girls. He enjoys being outdoors, doing yard work, taking walks, coaching girls’ softball, giving blood, and volunteering.

As value-based care continues to reshape payment models, many health systems struggle to balance financial performance with care quality goals. This session will offer practical strategies to use denial data, coding insights, and care coordination metrics to strengthen value-based outcomes—without sacrificing revenue. This discussion will highlight how to engage teams, optimize processes, and identify sustainable financial opportunities within value-based contracts.


Learning Objectives:

  • Learn how to use denial patterns and audit insights to improve documentation, coding accuracy, and contract performance.
  • Gain strategies to foster physician buy-in and leadership collaboration, finding “win-win” solutions that support both revenue integrity and value-based care success.
Revenue Cycle Management

Author:

Corella Lumpkins

Manager of Coding, Compliance and Provider Education
Loudoun Medical Group P.C.

Corella Lumpkins is the Manager of Coding, Compliance & Provider Education at Loudoun Medical Group (LMG) - one of the largest and most diverse physician-owned, multi-specialty Accountable Care Organizations in Northern Virginia/DC suburbs. As a subject matter expert, Corella has over 35 years of experience working in every area of the healthcare revenue cycle. Corella holds a bachelor’s degree and eleven certifications with an extensive background in auditing, billing, coding, implementing corporate compliance programs, CDI, education, denial and practice management. Prior to joining LMG, Corella has held leadership roles at Lifebridge, Medstar, Johns Hopkins and the University of Maryland health systems.

Corella is an author, adjunct faculty member and national speaker currently serving on both the AAPC National Advisory Board and Association of Clinical Documentation Integrity Specialists (ACDIS) Leadership Council. Corella works closely with providers in navigating patient-centric value-based care. 

... read more

Corella Lumpkins

Manager of Coding, Compliance and Provider Education
Loudoun Medical Group P.C.

Corella Lumpkins is the Manager of Coding, Compliance & Provider Education at Loudoun Medical Group (LMG) - one of the largest and most diverse physician-owned, multi-specialty Accountable Care Organizations in Northern Virginia/DC suburbs. As a subject matter expert, Corella has over 35 years of experience working in every area of the healthcare revenue cycle. Corella holds a bachelor’s degree and eleven certifications with an extensive background in auditing, billing, coding, implementing corporate compliance programs, CDI, education, denial and practice management. Prior to joining LMG, Corella has held leadership roles at Lifebridge, Medstar, Johns Hopkins and the University of Maryland health systems.

Corella is an author, adjunct faculty member and national speaker currently serving on both the AAPC National Advisory Board and Association of Clinical Documentation Integrity Specialists (ACDIS) Leadership Council. Corella works closely with providers in navigating patient-centric value-based care. 

As fraud schemes become increasingly complex, healthcare organizations must stay ahead of evolving threats that impact both clinical and financial integrity. This session will explore the latest fraud trends across the healthcare landscape - from billing manipulation and phantom providers to evolving schemes in hospice, home health, telehealth, and behavioral health. Join industry leaders as they share real-world examples, warning signs to watch for, and proactive strategies for detecting, preventing, and responding to fraud across care settings.

Payment Integrity

Author:

Peter Monson

Sr. Manager, Special Investigations Unit
UCare HP

Peter Monson is the Sr. Manager of the Special Investigations Unit at UCare, where he leads a team dedicated to preventing, detecting, and correcting fraud, waste, and abuse in health care claims. With more than a decade of investigative and leadership experience across health plans and state government, he has overseen some of the most significant Medicaid fraud cases in Minnesota’s history and has redesigned investigative practices to maximize efficiency and impact.

In addition to his role at UCare, Peter previously served as President of the Midwest Insurance Fraud Prevention Association, fostering collaboration between private insurers and government agencies to strengthen fraud prevention efforts. He holds a Bachelor of Science in Criminal Justice and minor in Psychology from North Dakota State University.

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Peter Monson

Sr. Manager, Special Investigations Unit
UCare HP

Peter Monson is the Sr. Manager of the Special Investigations Unit at UCare, where he leads a team dedicated to preventing, detecting, and correcting fraud, waste, and abuse in health care claims. With more than a decade of investigative and leadership experience across health plans and state government, he has overseen some of the most significant Medicaid fraud cases in Minnesota’s history and has redesigned investigative practices to maximize efficiency and impact.

In addition to his role at UCare, Peter previously served as President of the Midwest Insurance Fraud Prevention Association, fostering collaboration between private insurers and government agencies to strengthen fraud prevention efforts. He holds a Bachelor of Science in Criminal Justice and minor in Psychology from North Dakota State University.

Author:

Mandi Heiple

Director of Payment Integrity
Medica

Mandi Heiple is the Director of Payment Integrity at Medica, where she leads a high-performing team dedicated to ensuring accurate, compliant, and efficient claims payment across commercial and government lines of business. She oversees end-to-end payment integrity strategy – from prospective editing and coding validation to retrospective audits. Her teams drive measurable savings while protecting provider relationships and improving member experiences.

With over 20 years in healthcare operations and payment integrity, Mandi has focused on designing and implementing solutions that close process gaps, reduce improper payments, and strengthen compliance frameworks.

... read more

Mandi Heiple

Director of Payment Integrity
Medica

Mandi Heiple is the Director of Payment Integrity at Medica, where she leads a high-performing team dedicated to ensuring accurate, compliant, and efficient claims payment across commercial and government lines of business. She oversees end-to-end payment integrity strategy – from prospective editing and coding validation to retrospective audits. Her teams drive measurable savings while protecting provider relationships and improving member experiences.

With over 20 years in healthcare operations and payment integrity, Mandi has focused on designing and implementing solutions that close process gaps, reduce improper payments, and strengthen compliance frameworks.

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. 

Diagnosis codes and modifiers aren’t just billing details—they tell the story that determines how your claims are paid. When these elements don’t align, hospitals face denials, delays, and compliance risks. This session will break down how to accurately connect coding choices with billing practices to ensure claims reflect true clinical intent, reduce audit exposure, and secure appropriate reimbursement.


Learning Objectives:

  • Recognize the most common coding and modifier missteps that lead to denials and learn how to avoid them through stronger documentation and coding practices.
  • Implement strategies to bridge gaps between clinical, coding, and billing teams—ensuring consistent, compliant claims that tell the right story from documentation to payment.
Revenue Cycle Management

Author:

Stephanie Sjogren

Director, Coding and Provider Reimbursement
EmblemHealth/Connecticare

Stephanie Sjogren is a director of coding and provider reimbursement, working with payment integrity to ensure proper claims adjudication and to prevent fraud, waste, and abuse. Prior to joining ConnectiCare/EmblemHealth, she performed provider audits and education at a women’s healthcare group. Sjogren has also worked with physicians and staff to integrate and use electronic health record systems effectively and to stay in compliance with the Centers for Medicare & Medicaid Services’ rules and regulations. Her areas of specialty are payment integrity, auditing, and clinical documentation improvement. 

... read more

Stephanie Sjogren

Director, Coding and Provider Reimbursement
EmblemHealth/Connecticare

Stephanie Sjogren is a director of coding and provider reimbursement, working with payment integrity to ensure proper claims adjudication and to prevent fraud, waste, and abuse. Prior to joining ConnectiCare/EmblemHealth, she performed provider audits and education at a women’s healthcare group. Sjogren has also worked with physicians and staff to integrate and use electronic health record systems effectively and to stay in compliance with the Centers for Medicare & Medicaid Services’ rules and regulations. Her areas of specialty are payment integrity, auditing, and clinical documentation improvement. 

Industry benchmarks to measure the impact of payment integrity currently don't exist, making it challenging to optimize performance and areas of opportunity. Standards are extremely complicated due to varied member populations and an inconsistent approach to calculating metrics.
In this groundbreaking panel discussion, learn how a Working Group of payer and vendor SMEs have been collaborating over the last six months to develop a standard approach to calculating savings PMPM across LOB and audit programs. This session will share standard definitions and calculations, so attendees can understand how to calculate and compare their savings PMPM.
Payment Integrity
Moderator

Author:

Natalie Clayton

Head of Market Intelligence
Kisaco Research
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Natalie Clayton

Head of Market Intelligence
Kisaco Research

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.  

Author:

Dr. Priscilla Alfaro, MD, FAAP, CPC, CPMA, COC, CIC, CFE, CRC

VP Payment Integrity
Blue Cross NC

Dr. Priscilla Alfaro is a seasoned healthcare professional with extensive experience in executive medical management, fraud prevention, and healthcare analytics. A certified medical coder, fraud examiner, and auditor, she has a proven track record of improving healthcare efficiency and preventing fraud, waste, and abuse across various roles and affiliations, including the Texas HHS and Anthem.

... read more

Dr. Priscilla Alfaro, MD, FAAP, CPC, CPMA, COC, CIC, CFE, CRC

VP Payment Integrity
Blue Cross NC

Dr. Priscilla Alfaro is a seasoned healthcare professional with extensive experience in executive medical management, fraud prevention, and healthcare analytics. A certified medical coder, fraud examiner, and auditor, she has a proven track record of improving healthcare efficiency and preventing fraud, waste, and abuse across various roles and affiliations, including the Texas HHS and Anthem.

Author:

Karen Ballard

Director of Consulting Services
CGI

Karen Ballard is Director of Consulting Services, CGI, where she is responsible for managing the CGI ProperPay payment integrity platform. With a nearly 20-year career in the health payer space, Karen possesses a deep knowledge of claims processing, product management, payment integrity, and the Blue payer dynamic. Prior to joining CGI, Karen held a variety of positions in claims operations, BlueCard, and payment integrity during her 17-year tenure with Elevance Health (Anthem).

Karen holds a Bachelor of Arts and a Master of Business Administration from Southern New Hampshire University. She co-founded and previously co-facilitated the Blue PI Committee, comprised of payment integrity leaders from all 33 Blue Cross and Blue Shield plans and partnered with the Blue Cross and Blue Shield Association to drive change in the payment integrity space.

... read more

Karen Ballard

Director of Consulting Services
CGI

Karen Ballard is Director of Consulting Services, CGI, where she is responsible for managing the CGI ProperPay payment integrity platform. With a nearly 20-year career in the health payer space, Karen possesses a deep knowledge of claims processing, product management, payment integrity, and the Blue payer dynamic. Prior to joining CGI, Karen held a variety of positions in claims operations, BlueCard, and payment integrity during her 17-year tenure with Elevance Health (Anthem).

Karen holds a Bachelor of Arts and a Master of Business Administration from Southern New Hampshire University. She co-founded and previously co-facilitated the Blue PI Committee, comprised of payment integrity leaders from all 33 Blue Cross and Blue Shield plans and partnered with the Blue Cross and Blue Shield Association to drive change in the payment integrity space.