101 for modernization of each step of the claims continuum. 4 separate discussion across:
There are limited seats on each roundtable, so we recommend you reserve your space as soon as possible. Please select two (email [email protected] to reserve).
A) Itemized Bill Reviews
Moderator: Toni Case, Vice President National Sales, Ceris
B) Price Transparency
Moderator: Dave Cardelle, Chief Strategy Officer, Advanced Medical Solutions
C) The Changing World of Payment Integrity As it Relates to Value Based Care
Moderator: Lacey Crowl, Director, Claims Operations, Longevity Health Plan
D) Leverage Data Sources To Assure Membership Data Accuracy
Moderator: Morgan Tackett, Vice President Product, CAQH & Sherri Richardson, Strategy & Program Director, COB, Carelon
E) Top 3 ways to handle provider abrasion and manage clinical expenses
Moderator: Bob Starman, SVP Payment Integrity Solutions, Sagility
Payment Integrity
Revenue Integrity
Moderators
Lacey Crowl
VP of Health Plan Operations
Longevity Health Plan
Lacey Crowl is the Director of Claims Operations for Longevity Health Plan, responsible for the accuracy of claims processing focused on Medicare members. Lacey has experience in the Commercial, Medicare and Medicaid environments, developing prospective and retrospective payment integrity solutions for both clinical and claim coding reviews. She has operated within various claims processing platforms to develop, code and implement new audit concepts while operating within the Managed Care space.
Toni Case
Vice President, National Sales
CERIS
Morgan Tackett
Vice President Product
CAQH
Morgan Tackett is Vice President Product at CAQH. Over the last nine years, he has worked to build the portfolio of member and provider data solutions that CAQH offers to the industry. Prior to joining CAQH, Morgan spent 18 years at Blue Cross and Blue Shield of North Carolina, where he led teams in Member Service Operations, EDI Services, and Network Management. Morgan holds an MPH from the University of North Carolina at Chapel Hill.
Sherri Richardson
Strategy, Growth and Program Director
Carelon
As a strategic leader in Program Integrity Health Insurer industry and having mastered the world of “coordination of benefits”, Sherri is passionate about helping our customers and peers navigate the complex world of healthcare. With a proven track record of success in optimizing program efficiency and minimizing cost of care for Members who are eligible/entitled to two health coverages, Sherri is dedicated to ensuring the industry processes are focused on minimizing members out of pocket and provider/insurers administrative costs.
Sherri has 30+ years Health Insurer Industry experience. Operational Excellence, mapping program Strategy is Her Leadership background includes leading highly productive operational teams and all functions of COB Operations within the Commercial, Medicare, Affordable Care Act, Medicaid, Subrogation and Senior market.
As an Elevance/Carelon Corporate Presenter, Sherri enjoys developing training and motivational material, as well as sharing her knowledge and best practices related to maximizing Health Coverage with members, groups, providers and other insurer peers.
Sherri’s experience in health insurance runs deeps, having the privilege of leadership at Elevance/Carelon for 30+ years, and mentoring from industry leaders. Sherri is a life-long learner and strongly encourages others to learn and grow through continued experiences and educational opportunities.
On a personal note; As a prior Fitness Trainer, Sherri enjoys Weight Training, Yoga, Aerial Silks, and Master Swimming. Oftentimes joins the local 5K runs and loves to cook.
Bob Starman
SVP Payment Integrity Solutions
Sagility
Dave Cardelle
Chief Strategy Officer
AMS
Ceris Health
Website: https://www.ceris.com/
CERIS has 30 years of prepay and post pay claim review and repricing experience with a 97% client retention rate. Our solutions are deep, consistent, and defensible reviews, which make CERIS the partner of choice for health plans, Medicare and Medicaid plans, and third-party administrators. CERIS’ longstanding review services and clinical expertise offer incremental value and are grounded in a sincere dedication to our valued partners. CERIS' mission is to continue to grow and deliver long term Payment Integrity services for our partners and to help them save.
AMS Intelligent Analytics
Website: http://www.amspredict.com/
Advanced Medical Strategies (AMS) is the premier provider of payment integrity, risk management, and business intelligence solutions to identify and address excessive claims, prevent and recoup overpayments, and effectively manage the risks associated with high-cost claimants and group health underwriting.
Carelon
Website: https://www.carelon.com/
The health of the healthcare system improves when spending is responsible and accurate. Today, platform technology and advanced analytics are paving the way to make that more efficient and more proactive than ever before. Backed by decades of experience, Carelon’s Payment Integrity solutions bring together breakthrough technology and human expertise to help speed your ability to drive cost savings and value for your stakeholders.
Sagility
Website: https://sagilityhealth.com/
Sagility is a U.S.-based, tech-enabled healthcare business process management company that supports payers, providers, and their partners to deliver best-in-class operations, enhance the member and provider experience, improve the quality of care and promote health equity all while delivering cost-effective healthcare financial and clinical outcomes.
Sagility Technologies uses a holistic consulting approach to identify the root causes of healthcare payer and provider pain points, analyze the issues, and provide a complete solution that encompasses people, process, and technology platform improvements. Equipped with a strategic solutions mindset, our core focus is on what most benefits the client. Combining healthcare operations and technology experience with advanced UI, UX, and analytics expertise, we develop and deploy customized solutions for our client’s business. Additionally, with our extensive global resources and facilities, we provide the best service/price ratio for any service outsourcing needs.
- Investing in automated workflows
- Creating guidelines for the frequency of CDM updates
- Conducting system audits to locate the origin of discrepancies
- Defining Clinical Validation
- Coding Guidelines vs CMS Guidelines
- Common Conditions for Clinical Validation
- Monetary Savings and Case Studies
Payment Integrity
Katreece Baker
VP of Clinical Operations
DRG Claims Management
DRG Claims
Website: https://www.drgclaims.com/
DRG Claims Management (DCM) has been offering cost containment solutions to health plans across the United States since 2013. Our services include:
- Hospital Claim Audits (MS/APR DRGs and APC)
- Additional hospital audits
- Cost Outliers
- Readmissions
- Short-Stay/OBS
- Skilled Nursing Facility (PDPM/RUGs) audits
Our models include:
Post-payment Model: Focuses on addressing inaccurate coding and clinical errors retrospectively, maintaining good relationships with providers, and ensuring a smooth refund request process.
Prepayment Model: Preferred by health plans to prevent overpayments, reduce turnaround time, increase provider response, and ensure the audit of out-of-network claims.
- Complement your staff with data mining experts who identify hard to find claim overpayments.
- Stay ahead of constant claim leakage. Use expertise to detect new savings opportunities.
- Improve your medical loss ratio: Return claim dollars to your team/company/bottom line.
Payment Integrity
Kathy Gonzales-Byrd
Chief Strategy Officer
MedReview
Kathy Gonzales is the Chief of Staff, collaborating with the CEO and other senior leaders on revenue growth, process improvement and organizational effectiveness. Kathy oversees new client implementations and operations for key strategic accounts; manages the organization’s strategic planning process; and oversees interdepartmental accountability processes to ensure operational efficiency.
Before joining MedReview’s senior leadership team, Kathy served as Vice President, Payment Recovery for Cotiviti, Inc. overseeing claim audit operations and client management for Blue Cross Blue Shield accounts. She also has a long-standing consulting career, which include leadership roles in healthcare revenue cycle and organization effectiveness with Accenture and Ernst & Young.
Kathy has a bachelor’s degree in psychology from West Chester University of Pennsylvania, and a master’s degree in business administration (MBA) and Health Care Administration and Finance from Widener University.
MedReview
Website: https://www.medreview.us/
MedReview sets itself apart with over 50 years of experience delivering physician-approved pre-pay and post-pay payment integrity services that prioritize billing and payment quality, accuracy, and precision. Every claim reassigned by MedReview is reviewed, approved, and documented by a team of physicians, resulting in the industry’s lowest appeal overturn rate.
Utilizing proprietary technology combined with extensive subject matter clinical and administrative expertise, we achieve a 40% or greater reassignment rate focused on our clients’ specific needs. MedReview provides the full spectrum of payment integrity solutions including DRG and clinical reviews, cost outlier audits, re-admission reviews, data mining and itemized bill reviews.
Partnered with clients across the country, MedReview offers a flexible approach, supporting both complete outsourcing and supplemental enhancements to existing programs. By optimizing recoveries, preventing overpayments, and improving the provider experience, MedReview empowers payors to navigate the complexities of payment integrity with confidence and measurable success.
- Unveiling the audit landscape and understanding the importance of timely responses
- Expediting audit responses through the establishment of a dedicated audit response team, implementing
standardized documentation and track systems, and utilizing advanced technologies
- Discussing the value of analyzing audit findings and leveraging them as opportunities for continuous
improvement in revenue cycle management
Revenue Integrity
Payment Integrity
Michael Taylor
Senior Fraud Analyst, Medicaid Fraud Control Unit
West Virginia
Stuart Epling
Assistant Director, Office of Program Integrity
West Virginia
- Providing an overview of the No Surprises Act, an explanation of key provisions, and the impact it has had on
provider billing practices
- Highlighting how the No Surprises Act has influenced provider-payer interactions and insights into new
payment methodologies introduced by the act to resolve billing disputes
- Examples of how providers have adapted their practices to comply with the act
Revenue Integrity