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

Timely access to medical records is essential to accurate claims decisions, yet fragmented intake, manual provider outreach, and limited visibility create delays and administrative burden for both payers and providers. This roundtable will explore how a more structured, transparent retrieval experience can reduce friction today—while greater interoperability and digital fulfillment create a foundation for faster, more accurate claims adjustments in the future.

In partnership with AMPS.

In partnership with Optum

• Developing a roadmap for effective clinical data integration into pre-pay PI decision making and workflows
• Reimagining the PI process – new capabilities, collaboration, and upscaling staff
• Lessons learned while shifting from traditional post-pay operations and governance

In partnership with Claritev

Payment integrity is evolving from a downstream claims audit function to a proactive, critical lever for upstream cost avoidance. Payment integrity leaders note that ‘shifting left’ can cut administrative duties by at least 10-15%, in addition to improving provider abrasion. But evolving to cost avoidance not only requires a shift in mindset, but an evolution in how data, AI tools, and cross-functional collaboration are used to enable proactive decision making.

• Case studies: Critical strategies for launching pre-pay programs and measuring ROI
• How AI is expanding pre-pay capabilities and required governance
• Rethinking the impact and attribution of provider education initiatives

In partnership with Optum

The payment integrity vendor landscape has expanded rapidly, with plans now juggling specialist partners across pre-pay, post-pay, DRG validation, COB, FWA, clinical review, and an ever-growing list of AI-enabled point solutions. While each vendor promises incremental savings, the cumulative cost of sourcing, contracting, onboarding, integrating, and reconciling reporting across a sprawling stack is becoming a payment integrity problem in its own right. This panel brings together PI leaders who have wrestled with rationalising their vendor ecosystems to share practical approaches for building a leaner, better-orchestrated, and easier-to-manage vendor stack without losing savings yield.

• How to evaluate and source new vendors efficiently, including which proof points and pilot structures actually predict in-production performance
• Designing a waterfall and integration model that minimises duplicate findings, claim leakage, and operational drag across multiple vendors
• Consolidating vendor reporting and KPIs into a single view so PI leaders can defend total program value to senior leadership

Code updates. Site-of-service rule changes. Specialty drug billing classifications. Telehealth policy still being written. Coding technology evolving. The environment that edit programs have to keep up with in 2026 is more complex than it has ever been, and an annual review cycle is not enough. This session looks at what a well-governed, modern, continuously maintained edit program looks like in practice, where the most costly gaps tend to open and how technology can keep your plan ahead. 

• How to build an edit governance process that keeps pace with frequent policy changes across multiple lines of business
• Where the highest-risk edit gaps are opening right now and how to prioritise closing them without expanding every programme at once
• How to defend edits in provider disputes when the underlying policy they are based on is itself in transition

In partnership with Shift Technology