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Session Takeaways:

1. The OON pricing problem is bigger than most plans realize
Out-of-network claims carry disproportionate financial risk and most health plans are still relying on retrospective processes to catch what should have been stopped before payment. Oscar will share what they found when they looked hard at their own exposure.
2. Pricing alone isn't enough, payment integrity has to be part of the package
Repricing an OON claim gets you part of the way there. But without payment integrity embedded in the same process, plans are leaving significant savings on the table. We will share how integrating PI into OON workflow changes what is captured.
3. Speed and accuracy are not a tradeoff
A common concern among payers is that more rigorous pre-payment review slows claims processing. 
4. What good partnership actually looks like in practice
Not all payment integrity vendors operate the same way. Oscar will speak candidly about what they needed from a partner, what ClaimInsight delivered, and what other plans should be asking for when they evaluate their options.

In partnership with AMPS

Author:

Mark Noel

SVP, GM ClaimInsight
Advanced Medical Pricing Solutions
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Mark Noel

SVP, GM ClaimInsight
Advanced Medical Pricing Solutions

Author:

Rob Verrengia

Senior Vice President , Insurance Operations
Oscar Health
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Rob Verrengia

Senior Vice President , Insurance Operations
Oscar Health

In this session, the Working Group shares the first exclusive savings PMPM benchmarks, including insight on methodology, process, outcomes, and plans moving forward. Attendees will share feedback and recommendations for the next iterations of benchmarks. The session will include breakout roundtables focused on best practices to exceed benchmarks by PI program and line of business.

  • Presentation of baseline savings PMPM benchmarks
  • Audience feedback on next benchmark iterations
  • Breakout roundtable discussions focused on achieving benchmarks by PI program
Moderator

Author:

Natalie Clayton

Head of Market Intelligence
Kisaco Research
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Natalie Clayton

Head of Market Intelligence
Kisaco Research
 

Darshak Sanghavi

Chief Medical Officer
Machinify

Darshak Sanghavi, MD, is Chief Medical Officer of Machinify.

Read full bio

Darshak Sanghavi

Chief Medical Officer
Machinify

Darshak Sanghavi

Chief Medical Officer
Machinify

Darshak Sanghavi, MD, is Chief Medical Officer of Machinify.

Recently, he was one of the first Program Managers at the Advanced Research Projects Agency for Health (ARPA-H), a new multibillion dollar U.S. agency that the President tasked with developing health programs “so bold no one else, not even the private sector, is willing to give them a chance.” Overseeing an investment portfolio of several hundred million dollars, his programs cover cures for rare genetic diseases, regenerative medicine, women’s health, organ transplantation, innovative payment and business models for prevention, and many other areas.

Prior, he was Global Chief Medical and Clinical Operating Officer for Babylon, the global end-to-end digital health care provider serving over a dozen countries and over 24 million people, with the mission of bringing “affordable and accessible health care to everyone on Earth.” He was a member of the senior leadership team taking the company public in 2021 and oversaw a team of 1500 in the company’s global operations in the United States, United Kingdom, and Rwanda with revenues exceeding $1B. He is the former Chief Medical Officer of UnitedHealthcare’s Medicare & Retirement, the largest U.S. commercial Medicare program with over $90B in annual revenue, where he directed major national clinical and affordability programs. Earlier, he was Chief Medical Officer at OptumLabs, the R&D hub of UnitedHealth Group, running a portfolio of industry-leading projects with dozens of academic, government, and industry partners.

Before then, he served in a senior role in the federal government, as the Director of Preventive and Population Health at the Center for Medicare and Medicaid Innovation, where he directed the development of large pilot programs aimed at improving the nation’s health care costs and quality. In this capacity, he was the architect of the Accountable Health Communities model, the Million Hearts Cardiovascular Risk Reduction model, and the Medicare Diabetes Prevention Program, impacting tens of millions of Medicare beneficiaries. He was a fellow and managing director of the non-partisan Brookings Institution, and chief of pediatric cardiology at UMass Medical School (where he still sees patients). He’s an award-winning medical educator, has worked around the world and published dozens of scientific papers on topics ranging from the molecular biology of cell death to tuberculosis transmission in Peruvian slums.

A frequent guest on NBC’s Today and past commentator for NPR’s All Things Considered, Dr. Sanghavi was a columnist with Slate, the New York Times, Boston Globe, and Washington Post. His best-seller, A Map of the Child: A Pediatrician’s Tour of the Body, was named a best health book of the year by the Wall Street Journal. He previously worked as a U.S. Indian Health Service pediatrician on a Navajo reservation.

Educated at Harvard and Johns Hopkins, he completed his residency in pediatrics and fellowship in pediatric cardiology at Boston Children’s Hospital.