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This session will focus on:

  • California’s efforts to combat fraud, waste and abuse in Medi-Cal, California’s Medicaid program.
  • How California is exploiting available data and data sharing opportunities for purposes of Medicaid program integrity objectives.

  • A summary of program integrity best practices from the perspective of a Medicaid Program Integrity Director.

  • California’s future vision with regards to the use of data and data analytics to support its Medi-Cal fraud-control strategy.

Learning Objectives:

  • Obtain program integrity best practices that can be leveraged by the participating entity.
  • Discover new ways to exploit data to identify and develop actionable leads.

  • Performance metrics and return on investment – ways to measure success.

Author:

Bruce Lim

Deputy Director, Audits and Investigations
California Department of Health Care Services (DHCS)

Bruce Lim serves as the Deputy Director, Audits and Investigations, for the California Department of Health Care Services (DHCS) and is the designated Program Integrity Director for Medi-Cal, California’s Medicaid program. Mr. Lim is a certified public accountant (CPA) with over 32 years of audit and financial management experience in both the private and public sectors. Past employers include Kenneth Leventhal and Company, CPAs (Ernst & Young Kenneth Leventhal Real Estate Group), Packard Bell NEC, and the California Department of Food and Agriculture.

Bruce Lim

Deputy Director, Audits and Investigations
California Department of Health Care Services (DHCS)

Bruce Lim serves as the Deputy Director, Audits and Investigations, for the California Department of Health Care Services (DHCS) and is the designated Program Integrity Director for Medi-Cal, California’s Medicaid program. Mr. Lim is a certified public accountant (CPA) with over 32 years of audit and financial management experience in both the private and public sectors. Past employers include Kenneth Leventhal and Company, CPAs (Ernst & Young Kenneth Leventhal Real Estate Group), Packard Bell NEC, and the California Department of Food and Agriculture.

This presentation will delve into the latest trends and tactics employed by fraudsters, providing actionable insights to safeguard your organization. Attendees will gain a comprehensive understanding of the evolving threat landscape, learn to identify red flags, and implement effective prevention strategies.

Author:

Crystal Son

Executive Director of Enterprise Data Analytics Solutions
HCSC

Crystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC). She has 19 years of experience in deriving intelligence from data. 

At HCSC, she leads the Strategic Initiatives & Partnerships team, a department that focuses on cross-functional, collaborative analytics delivery on key programs such as Payment Integrity and Stakeholder Engagement, enterprise data and analytics strategy and planning, as well as design and execution of HCSC’s Responsible AI program. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.

Crystal Son

Executive Director of Enterprise Data Analytics Solutions
HCSC

Crystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC). She has 19 years of experience in deriving intelligence from data. 

At HCSC, she leads the Strategic Initiatives & Partnerships team, a department that focuses on cross-functional, collaborative analytics delivery on key programs such as Payment Integrity and Stakeholder Engagement, enterprise data and analytics strategy and planning, as well as design and execution of HCSC’s Responsible AI program. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.

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.

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.

Author:

Christopher Draven

Senior Director of Payment Integrity Analytics & AI
HCSC

Christopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.

Christopher Draven

Senior Director of Payment Integrity Analytics & AI
HCSC

Christopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.

Author:

Crystal Son

Executive Director of Enterprise Data Analytics Solutions
HCSC

Crystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC). She has 19 years of experience in deriving intelligence from data. 

At HCSC, she leads the Strategic Initiatives & Partnerships team, a department that focuses on cross-functional, collaborative analytics delivery on key programs such as Payment Integrity and Stakeholder Engagement, enterprise data and analytics strategy and planning, as well as design and execution of HCSC’s Responsible AI program. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.

Crystal Son

Executive Director of Enterprise Data Analytics Solutions
HCSC

Crystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC). She has 19 years of experience in deriving intelligence from data. 

At HCSC, she leads the Strategic Initiatives & Partnerships team, a department that focuses on cross-functional, collaborative analytics delivery on key programs such as Payment Integrity and Stakeholder Engagement, enterprise data and analytics strategy and planning, as well as design and execution of HCSC’s Responsible AI program. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.

This session will bring together payers and providers to discuss the challenges and opportunities presented by healthcare mandates and electronic medical record systems. Participants will explore strategies for effective collaboration to improve patient care and reduce administrative burdens.

Payment Integrity

Author:

Lourdes Centeno Fanjoy

Subject Matter Expert
Independent

With over 15 years of experience in revenue cycle management, compliance, payer policy advising, and executive presentations, Lourdes is a results-oriented leader dedicated to optimizing operational strategies and driving corporate success. Her resource allocation, process redesign, and capacity planning skills enable her to enhance profit margins and achieve strategic goals. Lourdes brings expertise in Medicare and Medicaid reimbursement policies, ensuring effective and compliant financial practices.

Lourdes Centeno Fanjoy

Subject Matter Expert
Independent

With over 15 years of experience in revenue cycle management, compliance, payer policy advising, and executive presentations, Lourdes is a results-oriented leader dedicated to optimizing operational strategies and driving corporate success. Her resource allocation, process redesign, and capacity planning skills enable her to enhance profit margins and achieve strategic goals. Lourdes brings expertise in Medicare and Medicaid reimbursement policies, ensuring effective and compliant financial practices.

Showcasing one health plan’s process for creating a pre-payment system focused on reducing provider abrasion by paying more claims correctly the first time.

Payment Integrity

Author:

Jordan Limperis

Data Scientist
LA Care

Highly motivated Data Scientist with a strong background in healthcare data and systems. Experienced in Inpatient Hospital and Laboratory Epic Systems, where I applied data-driven insights to improve clinical and operational efficiency. Currently, I am pursuing my career at L.A. Care, focusing leveraging advanced machine learning techniques to analyze noisy data, ensuring accuracy and efficiency in healthcare operations, particularly in payment integrity.

Jordan Limperis

Data Scientist
LA Care

Highly motivated Data Scientist with a strong background in healthcare data and systems. Experienced in Inpatient Hospital and Laboratory Epic Systems, where I applied data-driven insights to improve clinical and operational efficiency. Currently, I am pursuing my career at L.A. Care, focusing leveraging advanced machine learning techniques to analyze noisy data, ensuring accuracy and efficiency in healthcare operations, particularly in payment integrity.

Author:

Edgar Dominguez

Claims Integrity Business Manager
LA Care

Healthcare Operations expert with 20+ years of healthcare payer experience including 12+ years in Claims Administration with multiple fortune 200 companies.  I’m currently focused on implementing payment integrity initiatives aimed at cost avoidance by the use of data analytics.  I am a firm believer that data science is the wave of the future and will afford the healthcare industry with boundless opportunities to mitigate waste and reduce overall healthcare costs.

Edgar Dominguez

Claims Integrity Business Manager
LA Care

Healthcare Operations expert with 20+ years of healthcare payer experience including 12+ years in Claims Administration with multiple fortune 200 companies.  I’m currently focused on implementing payment integrity initiatives aimed at cost avoidance by the use of data analytics.  I am a firm believer that data science is the wave of the future and will afford the healthcare industry with boundless opportunities to mitigate waste and reduce overall healthcare costs.

  • In this session, we will delve into the practical applications of automation and data analytics, driving toward highest efficiency and effectiveness in your work, showcasing their benefits and limitations. We'll discuss real-life examples to illustrate the tasks AI can efficiently handle and the areas where human expertise remains crucial. Attendees will gain a comprehensive understanding of how these technologies can be leveraged within the sector, as well as insights on when to consider hiring or training staff to complement and enhance these tools.
  • Learning Objectives: Understand how key automation, including AI, can increase accuracy, consistency and throughput in your operations - Explore how shifts in inventory prioritization can deliver higher results in other insurance identification
Payment Integrity

Author:

Beth Franke

Staff Vice President, Payment Integrity Coordination of Benefits
Elevance/Anthem

Beth Franke started her career in the healthcare industry over 30 years ago. During that time, she has held management and leadership positions within large healthcare organizations such as Elevance Heath, Humana, Inc. and Kindred Healthcare and served as principal consultant for the Commonwealth of Kentucky, launching the state’s first self-funded health insurance model. She has also managed multi-discipline teams within special investigations, claims, enrollment and billing, corporate applications, mobile strategy, care management and enterprise project management office. Her current role as Staff Vice President has positioned her to oversee the Coordination of Benefits organization in Payment Integrity with over 500+ associates.

Beth has a BS in Mathematics and Computer Science from Centre College. She is a Project Management Professional (PMP), a Certified Professional Coder (CPC) and earned a Master Six Sigma Black Belt (MBB) certification from Villanova University. She also serves as a certified professional coach and was recognized as an Emerging Leader at Elevance Health.

Beth and her husband line in Louisville, KY and have five adult children. She enjoys hiking, biking and traveling with her family and is also active with several volunteer organizations, providing food, shelter, and other needed services for those less fortunate.

Beth Franke

Staff Vice President, Payment Integrity Coordination of Benefits
Elevance/Anthem

Beth Franke started her career in the healthcare industry over 30 years ago. During that time, she has held management and leadership positions within large healthcare organizations such as Elevance Heath, Humana, Inc. and Kindred Healthcare and served as principal consultant for the Commonwealth of Kentucky, launching the state’s first self-funded health insurance model. She has also managed multi-discipline teams within special investigations, claims, enrollment and billing, corporate applications, mobile strategy, care management and enterprise project management office. Her current role as Staff Vice President has positioned her to oversee the Coordination of Benefits organization in Payment Integrity with over 500+ associates.

Beth has a BS in Mathematics and Computer Science from Centre College. She is a Project Management Professional (PMP), a Certified Professional Coder (CPC) and earned a Master Six Sigma Black Belt (MBB) certification from Villanova University. She also serves as a certified professional coach and was recognized as an Emerging Leader at Elevance Health.

Beth and her husband line in Louisville, KY and have five adult children. She enjoys hiking, biking and traveling with her family and is also active with several volunteer organizations, providing food, shelter, and other needed services for those less fortunate.

Payment Integrity

Author:

Helen Liu, Pharm.D.

Health Plan Leader
Independent

Helen Liu, PharmD, brings 29 years of diverse pharmacy experience, blending clinical expertise, operational efficiency, technological innovation, and management across various healthcare settings.
Over the past four years, Helen has successfully led pharmacy operations at ATRIO Health Plans (Medicare), achieving significant milestones in PA/ST, FWA, MTM programs, resulting in over $4.5M in savings. She’s conducted formulary analyses to support actuary Medicare annual bid submissions, including IRA and M3P programs, collaborated with partners and the Pharmacy Benefit Manager (PBM) to identify cost-saving opportunities through formulary alternatives, biosimilars, and rebate strategies, and partnered in the RFP PBM selection process and resolved complex pharmacy-related issues through cross-departmental collaboration.
Before ATRIO, Helen spent seven years at Kaiser Permanente, where she served as Regional Assistant Director to implement hospitals Drug Use Management Program. Her efforts led to over $20 million in savings through inventory management, drug cost-saving initiatives, and the standardization of clinical content/practice guidelines.

Helen Liu, Pharm.D.

Health Plan Leader
Independent

Helen Liu, PharmD, brings 29 years of diverse pharmacy experience, blending clinical expertise, operational efficiency, technological innovation, and management across various healthcare settings.
Over the past four years, Helen has successfully led pharmacy operations at ATRIO Health Plans (Medicare), achieving significant milestones in PA/ST, FWA, MTM programs, resulting in over $4.5M in savings. She’s conducted formulary analyses to support actuary Medicare annual bid submissions, including IRA and M3P programs, collaborated with partners and the Pharmacy Benefit Manager (PBM) to identify cost-saving opportunities through formulary alternatives, biosimilars, and rebate strategies, and partnered in the RFP PBM selection process and resolved complex pharmacy-related issues through cross-departmental collaboration.
Before ATRIO, Helen spent seven years at Kaiser Permanente, where she served as Regional Assistant Director to implement hospitals Drug Use Management Program. Her efforts led to over $20 million in savings through inventory management, drug cost-saving initiatives, and the standardization of clinical content/practice guidelines.