| Page 227 | Kisaco Research

CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM

Strategies for identifying savings and reducing costs in pharmacy operations through:

-            Formulary design and management

-            Inventory control and standardization

-            Utilization management

-            Provider engagement

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.

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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.

  1. Round Table 1: AI V Human: Dealing with Complex Claims

Discussion around where artificial intelligence has beneficial uses and where human expertise is necessary to achieve results- with a specific focus on complex claim review

  1. Round Table 2: Create Contracts that Work for You

Identifying how contract language can be altered to ensure you limit unnecessary payments and save money “indirectly”

  1. Round Table 3: Meeting Requirements for Interoperability

Meeting interoperability requirements and ensuring EHR exchange is efficient for appropriate patient care and timely coverage decisions

CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM

  • Establish governance strategies through varying development stages of payment integrity functions to maximize operational expenditure 

Author:

Josh Miller

Director, Payment Integrity
Prominence
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Josh Miller

Director, Payment Integrity
Prominence

CEU Eligibility: COC, CPC, CPC-P, CPB, CPCO, CPMA, CPPM

To address the increasingly high costs and large product variation of implant devices it is important to develop an implant payment integrity program and policy. This promotes transparency between payer and provider, in addition to a more predictable implant and device spend, potentially lowering medical spend and healthcare costs. This can be achieved by utilizing evidence-based clinical guidelines, industry standard reimbursement methodologies and contracting. In addition, develop reporting and a claims review process to detect safety and quality gaps in implant usage to recoup or stop potential overpayments.

Learning Objectives:

-            Outpatient Outlier Payments for Claims

-            Credits for Replaced Medical Devices

-            Best practices for payer implant policy creation

-            Trends in inappropriate implant usage and billing

Author:

Stephanie Sjogren

Director, Coding and Provider Reimbursement
EmblemHealth/Connecticare

Stephanie Sjogren is a director of coding and provider reimbursement, working with payment integrity to ensure proper claims adjudication and to prevent fraud, waste, and abuse. Prior to joining ConnectiCare/EmblemHealth, she performed provider audits and education at a women’s healthcare group. Sjogren has also worked with physicians and staff to integrate and use electronic health record systems effectively and to stay in compliance with the Centers for Medicare & Medicaid Services’ rules and regulations. Her areas of specialty are payment integrity, auditing, and clinical documentation improvement. 

... read more

Stephanie Sjogren

Director, Coding and Provider Reimbursement
EmblemHealth/Connecticare

Stephanie Sjogren is a director of coding and provider reimbursement, working with payment integrity to ensure proper claims adjudication and to prevent fraud, waste, and abuse. Prior to joining ConnectiCare/EmblemHealth, she performed provider audits and education at a women’s healthcare group. Sjogren has also worked with physicians and staff to integrate and use electronic health record systems effectively and to stay in compliance with the Centers for Medicare & Medicaid Services’ rules and regulations. Her areas of specialty are payment integrity, auditing, and clinical documentation improvement.