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Keeping Your Edit Program Current When the Rules Keep Changing

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

Moderator

Author:

Jesse Montgomery

Head of US Healthcare Customer Success & Value Engineering

Shift Technology

Leading Healthcare Customer Success and Value Engineering, my mission has been focused on transforming customer engagement through a fusion of industry knowledge, data science, and personalized service strategies. Leverage my strategic partnerships to advance collaborative successes, resulting in the development of creative and innovative healthcare solutions and capability expansion for Shift Technology focused on payment integrity, ultimately enhancing our customer commitments and financial targets.

Panelists

Author:

Dr. Priscilla Alfaro

Strategic Advisor, Cost Containment & Payment Transformation

Dr. Priscilla Alfaro is a seasoned healthcare professional with extensive experience in executive medical management, fraud prevention, and healthcare analytics. A certified medical coder, fraud examiner, and auditor, she has a proven track record of improving healthcare efficiency and preventing fraud, waste, and abuse across various roles and affiliations, including the Texas HHS and Anthem.

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From Fragmented Data to Shared Intelligence

State program integrity teams, MCO SIUs, and partners are moving beyond static reporting toward real-time collaboration models that improve visibility and coordination. This panel explores how shared data and centralized platforms are enabling earlier detection, stronger oversight, and more aligned decision-making across the ecosystem.

How a centralized portal enables real-time information exchange between OIGs, MCOs, SIUs, and partners
The impact of shared intelligence on identifying high-risk providers and managing overpayments
How improved collaboration is influencing actuarial processes and managed care rate setting

In partnership with HMS, Gainwell

Moderator

Author:

Dr Gary Call

Chief Medical Officer

HMS

Dr. Gary Call is a board-certified family physician and senior healthcare executive with extensive experience in managed care operations and payment integrity.

Dr. Call is nationally recognized for his leadership in payment integrity and FWA prevention, including advanced analytics, clinical review strategies, and technology-enabled solutions that protect both government and commercial payer programs from improper payments and emerging integrity risks.

As Chief Medical Officer at HMS, Dr. Call oversees Payment Integrity, Care Management, Clinical Analytics, and Population Health Solutions, driving innovation and clinical programs that improve outcomes, strengthen program integrity, and support the financial sustainability of state healthcare programs.

Panelists

Author:

Brian Dunn

Inspector General

Illinois Department of Healthcare and Family Services

Brian Dunn serves as the Inspector General for the Illinois Department of Healthcare and Family Services, where he oversees program integrity efforts for the state’s $37 billion Medicaid program. In this role, he directs criminal and civil investigations, audits, and compliance reviews, and the data analysis that supports this work. Prior to this, Brian served as First Deputy Inspector General and General Counsel for the City of Chicago’s Office of Inspector General. Before leading government oversight work, Brian’s legal career included serving as the General Counsel for the Illinois Department of Human Services and the Illinois Department of Commerce and Economic Opportunity, a litigation associate for a global law firm, and a law clerk for a federal district judge.

Author:

James Vanderberg

Director, Special Investigations Unit

HCSC

James Vanderberg is a Director at HCSC with seven years of experience in the organization’s Special Investigations Department. He currently oversees fraud, waste, and abuse (FWA) operations for government programs.

Prior to joining HCSC, James served with the U.S. Department of Labor, Office of Inspector General, where he retired as the Special Agent in Charge for the Chicago Region. In this role, he led administrative, civil, and criminal investigations involving fraud, waste, and abuse across medical, unemployment, and job training benefits and grants.

Author:

Kevin O'Donnell

Director of the Division of Program Integrity

D.C. Department of Health Care Finance

Kevin O’Donnell is the Director of the Division of Program Integrity for the D.C. Department of Health Care Finance, the District’s Medicaid agency. He has served in that role since November 2021. In that capacity, he oversees the Medicaid agency’s Fraud, Waste, and Abuse activities, coordinating and supervising audits and investigations of Medicaid enrolled providers. To ensure the Medicaid program is effectively rooting out FWA, Mr. O’Donnell collaborates with public and private partners, including law enforcement agencies, regulatory agencies, Managed Care Organizations, and others.

Prior to becoming the Director of the DPI, Mr. O’Donnell spent 7 years as an Attorney-Advisor in DHCF’s Office of the General Counsel, where he defended the agency in administrative appeals before the D.C. Office of Administrative Hearings. Mr. O’Donnell is a graduate of the George Washington University School of Law and a native Washingtonian.

Read more about From Fragmented Data to Shared Intelligence

From Fragmented Data to Shared Intelligence

Read more about From Fragmented Data to Shared Intelligence

From Fragmented Data to Shared Intelligence

Key discussion points:
- How state agencies and managed care organisations can build collaborative infrastructure to facilitate information exchange among MCO SIUs, oversight bodies, actuaries, and auditors
- Impact of shared information exchange on anomaly detection, high risk providers, and overpayment management
- How improved collaboration impacted managed care rate setting

Author:

Brian Dunn

Inspector General

Illinois Department of Healthcare and Family Services

Brian Dunn serves as the Inspector General for the Illinois Department of Healthcare and Family Services, where he oversees program integrity efforts for the state’s $37 billion Medicaid program. In this role, he directs criminal and civil investigations, audits, and compliance reviews, and the data analysis that supports this work. Prior to this, Brian served as First Deputy Inspector General and General Counsel for the City of Chicago’s Office of Inspector General. Before leading government oversight work, Brian’s legal career included serving as the General Counsel for the Illinois Department of Human Services and the Illinois Department of Commerce and Economic Opportunity, a litigation associate for a global law firm, and a law clerk for a federal district judge.

Read more about From Fragmented Data to Shared Intelligence

From Fragmented Data to Shared Intelligence

Read more about From Fragmented Data to Shared Intelligence

From Fragmented Data to Shared Intelligence

Key discussion points:
- How state agencies and managed care organisations can build collaborative infrastructure to facilitate information exchange among MCO SIUs, oversight bodies, actuaries, and auditors
- Impact of shared information exchange on anomaly detection, high risk providers, and overpayment management
- How improved collaboration impacted managed care rate setting

Author:

Brian Dunn

Inspector General

Illinois Department of Healthcare and Family Services

Brian Dunn serves as the Inspector General for the Illinois Department of Healthcare and Family Services, where he oversees program integrity efforts for the state’s $37 billion Medicaid program. In this role, he directs criminal and civil investigations, audits, and compliance reviews, and the data analysis that supports this work. Prior to this, Brian served as First Deputy Inspector General and General Counsel for the City of Chicago’s Office of Inspector General. Before leading government oversight work, Brian’s legal career included serving as the General Counsel for the Illinois Department of Human Services and the Illinois Department of Commerce and Economic Opportunity, a litigation associate for a global law firm, and a law clerk for a federal district judge.

Read more about From Fragmented Data to Shared Intelligence

Coverage Without Compromise: A New Operating Model for DRG Validation

What does a health plan actually gain when it moves from random sampling DRG claims to smart triaging them? Horizon's Ron Jones and Alaffia's TJ Ademiluyi discuss the answer: shorter review cycles, a stronger case for bringing DRG review in-house, and a rigorous test of the approach against sepsis DRG, one of the more contested determinations in claims review.

In partnership with Alaffia Health

Moderator