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History of Hospital at Home and Telehealth Services
Post Pandemic Growth and Barriers
Hospital at Home vs Home Health

Reduced Payer and Provider Costs
Developing Reimbursement Policies
Identifying Potential Fraud, Waste and Abuse

Lesson objectives:

- Overall knowledge of hospital at home and telehealth services
- How to create effective reimbursement policies for emerging healthcare services

Author:

Cereasa Horner

Director of Policy and Payment Integrity
CERIS

Cereasa Horner, MHA, is the Director of Policy and Payment Integrity for CERIS, a CorVel company. Cereasa has been an integral part of the CERIS team since 2017, and throughout her tenure, she has consistently displayed a rare combination of leadership, innovation, and a deep understanding of the healthcare industry. Her dedication to the mission and values of CERIS Health has been evident in every aspect of her work. She has developed CERIS’ internal payment integrity program and partnered with health plans to create and implement reimbursement policies related to claim audits. 

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Cereasa Horner

Director of Policy and Payment Integrity
CERIS

Cereasa Horner, MHA, is the Director of Policy and Payment Integrity for CERIS, a CorVel company. Cereasa has been an integral part of the CERIS team since 2017, and throughout her tenure, she has consistently displayed a rare combination of leadership, innovation, and a deep understanding of the healthcare industry. Her dedication to the mission and values of CERIS Health has been evident in every aspect of her work. She has developed CERIS’ internal payment integrity program and partnered with health plans to create and implement reimbursement policies related to claim audits. 

Every payer can agree on one thing. There is fraud, waste, and abuse happening that they cannot see or see fast enough with the limitations of current claims data-centric technology stacks. One more technology in the stack doesn't solve the problem of not being able to see dynamic behaviors, relationships, and outliers that lead to over-payments on basic CMS edits as well as undetected complex fraud and collusion schemes. More claims data-centric technology is not the solution. Dynamic provider-centric risk detection technology coupled with continuously-credentialed provider integrity data is the solution for increased FWA detection and near real-time prevention. That's because stacks of claim data-centric technologies (even those using conventional artificial intelligence) will never see what providers are doing individually, in relationship with all other providers, and in relationship to all other claims on each-and-every claim submitted.

This session will focus on the benefits of a provider-centric FWA prevention approach powered by artificial intelligence that is dynamic and uses both supervised and unsupervised machine learning for detection beyond rules-based technologies. It will highlight strategies for FWA prevention at five points along the claims workflow including pre pre-payment, pre-payment, and post-payment positions. Fraud and SIU teams will be particularly interested in this combination of technologies to detect and automatically package fraud and collusion schemes you can’t see now or can’t see fast enough with the limitations of claim-centric approaches.

1. Understand the FWA detection limitations of claims data-centric approaches
2. Understand how a provider centric-approach such as Integr8 AI increases FWA detection and prevention
3. Understand the benefits of provider-centric FWA prevention pre pre-payment, pre-payment, and post-payment

Author:

Clay Wilemon

Chief Executive Officer
4L Data Intelligence, Inc.

Clay serves as CEO at 4L Data Intelligence™. He has launched over 500 new healthcare brands and holds patents in artificial intelligence and medical technologies. Clay is on the Board of Directors at Octane, a Southern California non-profit economic development organization that has helped hundreds of technology and med-tech companies get started. He a graduate of Vanderbilt University. 

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Clay Wilemon

Chief Executive Officer
4L Data Intelligence, Inc.

Clay serves as CEO at 4L Data Intelligence™. He has launched over 500 new healthcare brands and holds patents in artificial intelligence and medical technologies. Clay is on the Board of Directors at Octane, a Southern California non-profit economic development organization that has helped hundreds of technology and med-tech companies get started. He a graduate of Vanderbilt University. 

Author:

Greg Lyon

Senior Fraud Advisor
4L Data Intelligence, Inc.

Greg is a recognized anti-fraud expert with experience in Financial Services and Healthcare Payments that includes serving as Director of Fraud Prevention at United Healthcare. His guiding principle is, “The best way to fight fraud is to prevent it.” Greg is a graduate of Colgate University and is a Certified Financial Planner.

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Greg Lyon

Senior Fraud Advisor
4L Data Intelligence, Inc.

Greg is a recognized anti-fraud expert with experience in Financial Services and Healthcare Payments that includes serving as Director of Fraud Prevention at United Healthcare. His guiding principle is, “The best way to fight fraud is to prevent it.” Greg is a graduate of Colgate University and is a Certified Financial Planner.

  • This session delves into prevalent billing and coding errors encountered in healthcare reimbursement postpayment and prepayent processes, shedding light on their potential to result in overpayments for payers. Through case studies and practical examples, Healthcare Fraud Shield can showcase effective strategies for identifying common errors, such as incorrect billing of maternity care services.
  • This session will walk through:
      • Appropriate coding for delivery services 
      • Proper billing practices at it relates to antepartum and postpartum care 
      • How to detect patterns of inappropriate claim submissions

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. 

HPRI developed a first of it's kind, payment integrity industry survey, in partnership with the payers that are part of the HPRI network. The survey results are aggregated to provide powerful insights from all of the PI experts across the country. The aim of the survey was to evaluate current trends in the payment integrity market, explore the payer perspective of implications related to the complexity of the market, and gain insights from payers on the introduction of disruptive technologies enabling greater analytics for unstructured data, and
opportunities for future savings in the coming year. Join us for a review of the 2024 PI survey results to help drive your PI initiatives.

- Learn about the most prominent PI trends for 2024
- Explore new innovations and their impact on driving 2024 opportunites
- Leverage survey results to asses where your program and organization fall in relation to your peers in the industry

Author:

Dave Cardelle

Chief Strategy Officer
AMS
... read more

Dave Cardelle

Chief Strategy Officer
AMS
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