Different types of AI are rapidly evolving – from ML and NLP to GenAI and Agentic AI. Health Plans are still testing use cases, assessing ROI, and building the infrastructure to support implementation. PI leaders will share lessons learned so far in their efforts to build the foundation for AI to drive payment accuracy.
Building a successful Special Investigations Unit takes more than just hiring investigators. It requires the right mix of people, technology, and processes to detect and act on fraud across commercial, Medicaid, and pharmacy lines of business. In this session, Carl Reinhardt draws on over two decades of SIU leadership at Anthem to share a practical blueprint for building and scaling an effective investigations function. Attendees will learn.
In this panel discussion, payment integrity leaders will share how they are building data workflows that support day-to-day PI operations. The session will focus on how to move from fragmented systems and static reporting to connected, actionable workflows that enable earlier intervention and better decision-making.
Building a successful Special Investigations Unit takes more than just hiring investigators. It requires the right mix of people, technology, and processes to detect and act on fraud across commercial, Medicaid, and pharmacy lines of business. In this session, Carl Reinhardt draws on over two decades of SIU leadership at Anthem to share a practical blueprint for building and scaling an effective investigations function. Attendees will learn.
- The key roles, skill sets, and team structures needed to build an SIU from the ground up
- The tools and applications required to support investigations across multiple lines of business and geographies
- How to scale SIU operations as membership grows, and lessons learned from managing investigations across commercial and Medicaid populations
Lyric is the payment integrity Al company trusted by the nation's leading health plans at the beginning of the claims payment workflow. The Lyric platform is built on Al from the ground up and trained on 35 years of clinical expertise with real time integrations across 190 million lives. Lyric reduces wasted healthcare spending and ensures fast, accurate payments that drive transparency between payers and providers. Lyric is recognized as the 2025 Best in KLAS for Pre-payment Accuracy and Integrity.
How do we scale high-impact clinical integrity programs using smart targeting to reduce review volume while increasing savings?
In partnership with AMPS.
In partnership with Optum
Serving as Market President at Optum, Tisha has spent more than 25 years at the forefront of health plan innovation, helping clients build strategic, comprehensive programs to address their toughest challenges and achieve financial health and operational excellence at scale.
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.
