The impact of payment integrity spans across many lines of business, PI program types, cost avoidance and preventative initiatives. But the overall impact of PI is very hard to capture, especially when multiple vendors have different reporting strategies. Meanwhile, senior leadership is asking for overall PI savings. This session will share case studies and strategies for measuring and centralizing PI reporting to inform a value story for PI across the business.

• How plans are measuring PI savings, especially for pre-pay, preventative, and vendor-based programs
• Strategies to create a centralized portal to consolidate reporting of key KPIs and make visible for all stakeholders
• Opportunities for PI organizations to develop a metrics-based narrative that underscores its critical role in driving cost containment and affordability

In this fireside chat, the Chief of Healthcare Delivery will explain how LA Care has created a unique role and structure to align all functions across the PI continuum. Critical elements including data systems integration, AI use for anomaly detection, and clinical context will be addressed to demonstrate how LA Care is driving more effective pre-pay cost avoidance.

• Case Study:  Lessons learned from connecting UM to PI to Network Strategy
• Integrating data systems, clinical context, and AI for efficient pre-payment insights
• Ensuring services including hospice, skin substitutions, and lab testing are rendered correctly

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.

• How to structure governance to support implementation
• The framework for responsible use of AI
• Data quality management – preparing data amidst legacy systems and fragmentation

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