- 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
- Highlighting key pain points that healthcare organizations face in PI operations and how it impacts their operations
- Picture what other payer organization are doing to alleviate the pain points
- Talking about “what if” scenarios or successful use cases of technology, process, governance to help in PI operations
Payment Integrity
Ankur Verma
Vice President, Healthcare
Everest
- Elucidating the impact of value-based care on revenue cycle management, including the need for new
metric, payment models, and performance measures
- Revisiting existing RCM approaches and understanding how RCM can be optimized based on value
- Case studies of successful revenue cycle management transformations based on VBC principles
Revenue Integrity
Payment Integrity
Speakers
Phillip Churchill
Assistant General Counsel
Blue Cross Blue Shield of Michigan
Aaron Browder
President
Carelon Subrogation
Aaron Browder is Staff Vice President, Elevance Health and President, Carelon Subrogation, formerly Meridian Resource Company (Meridian), where he and his team are responsible for overseeing the successful implementation and execution of our clients’ end-to-end subrogation programs. With a nearly 20-year career in subrogation, Aaron possesses a deep knowledge of healthcare subrogation. He has held a wide range of management positions throughout his tenure at Meridian, most recently serving as Staff Vice President. Prior to joining Meridian, Aaron gained experience in the financial services and insurance industries with Arthur Andersen, LLP/KPMG, LLP, and Travelers Property Casualty.
Aaron holds a Bachelor of Arts degree from Indiana University and a Master of Business Administration from Butler University. He served on the Board of Directors for the National Association of Subrogation Professionals and has been a national presenter and author on issues related to subrogation.
Moderator
Kyle Pankey
Sales & Growth Leader
Carelon Subrogation
Kyle Pankey has over two decades of experience working within the healthcare and payer operations, with over 10 years specifically tied in to the payment integrity space. Kyle lives in Chattanooga, TN and has served as Carelon Subrogation’s growth leader since mid-2022.
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.