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Health Plans and Hospitals are looking to leverage Price Transparency Data to improve contracting, drive business intelligence and build Payment Integrity use cases.  This session lays out a 2024 road map choosing the right data set and the right partner while also exploring specific use cases for your plan or hospital.

*Understand 5 Key Questions you should be asking any Price Transparency vendor
*Identify specific use cases for Price Transparency Data that will be valuable to your organization

Author:

John-Michael Loke

SVP, Health Plan Strategy & Partnerships
AMS
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John-Michael Loke

SVP, Health Plan Strategy & Partnerships
AMS
  1. Learn strategies for identifying areas of overpayment in healthcare claims processing.
  2. Understand how technology and AI can be leveraged to predict and prevent high-cost overpayments.
  3. Explore best practices for reducing high-cost overpayments, to improve cost containment efforts.
Track 1: Advanced Payment Integrity Function

Author:

Thomas Everett

Subject Matter
Expert Independent
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Thomas Everett

Subject Matter
Expert Independent
  1. Evaluate the pros and cons of pre-pay and pay-and-chase approaches in payment integrity operations.
  2. Understand the circumstances under which each approach is most effective and how to choose the right strategy for your organization.
Track 2: Developing Payment Integrity Function

Author:

Dr Michael Seavers

Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics
Harrisburg University

Dr. Michael Seavers is the Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics at Harrisburg University.  Dr. Seavers has a varied background in IT, business, and healthcare spanning many decades.  Dr. Seavers began as a programmer analyst at Shared Medical Systems and later at General Electric in their Aerospace Division.  Dr. Seavers then worked in IT management in the pick-pack-and-ship industry being employed at companies like Book-of-the-Month Club (Time Warner) and Hanover Direct during the .COM expansion.

As the .COM industry went bust, Dr. Seavers moved to the healthcare industry.  Dr. Seavers worked at Capital BlueCross for nearly two decades.  The first decade was as a Senior Manager in the IT department and the second decade as the Senior Director of Claims and later the Senior Director of Enrollment and Billing.  Dr. Seavers focus was automation of labor utilizing software robotics for healthcare. 

After a varied career background and various formal degrees, Dr. Seavers is very pleased to be teaching at Harrisburg University.

... read more

Dr Michael Seavers

Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics
Harrisburg University

Dr. Michael Seavers is the Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics at Harrisburg University.  Dr. Seavers has a varied background in IT, business, and healthcare spanning many decades.  Dr. Seavers began as a programmer analyst at Shared Medical Systems and later at General Electric in their Aerospace Division.  Dr. Seavers then worked in IT management in the pick-pack-and-ship industry being employed at companies like Book-of-the-Month Club (Time Warner) and Hanover Direct during the .COM expansion.

As the .COM industry went bust, Dr. Seavers moved to the healthcare industry.  Dr. Seavers worked at Capital BlueCross for nearly two decades.  The first decade was as a Senior Manager in the IT department and the second decade as the Senior Director of Claims and later the Senior Director of Enrollment and Billing.  Dr. Seavers focus was automation of labor utilizing software robotics for healthcare. 

After a varied career background and various formal degrees, Dr. Seavers is very pleased to be teaching at Harrisburg University.

  1. Gain a comprehensive understanding of the fundamentals of artificial intelligence and its applications in payment integrity.
  2. Explore essential strategies for implementing AI in payment integrity operations to improve efficiency and accuracy – especially when lack of resources is a struggle.
  3. Learn from case studies about successful AI implementations and practical strategies for leveraging AI technologies.
Track 2: Developing Payment Integrity Function
  1. Explore some of the most effective uses of AI in Payment Integrity and understand its benefits.
  2. Highlight the role of AI in identifying fraudulent activities and streamlining fraud detection workflows.
  3. Learn about the specific processes within fraud identification where AI can make a significant contribution and where human input remains essential.
Track 1: Advanced Payment Integrity Function
  1. Learn effective strategies for recruiting and training payment integrity experts to build a high-performing team.
  2. Understand where to recruit talent from and how to identify individuals with the necessary skills for payment integrity roles.
  3. Gain insights into developing and nurturing payment integrity talent for long-term success.
Track 2: Developing Payment Integrity Function
  1. Learn how to develop a patient-centric claims management strategy that prioritizes inclusivity and transparency.
  2. Explore best practices for managing inpatient claims so as to enhance the patient experience.
  3. Understand the importance of inclusive claim management strategies in achieving payment integrity goals.
Track 1: Advanced Payment Integrity Function

Author:

Conor McCauley

Director, Payment Integrity Clinical Capabilites
Highmark Health

My name is Conor McCauley. I am the Director of Payment Integrity Clinical Capabilities at Highmark. Being a Critical Care nurse, it is easy to see there are issues surrounding healthcare funding. Inserting clinical insights into reimbursement methodologies can lead to affordability and improved patient outcomes. Clinicians are well positioned to make a difference here. My passion is developing an engaged team, effective processes, and surrounding clinicians with the right technology, data, and market insights so they can work at the top of their licensure.

... read more

Conor McCauley

Director, Payment Integrity Clinical Capabilites
Highmark Health

My name is Conor McCauley. I am the Director of Payment Integrity Clinical Capabilities at Highmark. Being a Critical Care nurse, it is easy to see there are issues surrounding healthcare funding. Inserting clinical insights into reimbursement methodologies can lead to affordability and improved patient outcomes. Clinicians are well positioned to make a difference here. My passion is developing an engaged team, effective processes, and surrounding clinicians with the right technology, data, and market insights so they can work at the top of their licensure.

Author:

Drew Satriano

Vice President of Payment Integrity
Highmark Health

Drew Satriano, a seasoned professional with an MBA, CPA, CFE, and JD, brings extensive expertise in payment integrity, accounting, auditing, and legal matters within regulated environments. Notably, he has spearheaded innovative initiatives resulting in a 968% increase in savings since 2014. His recent focus includes leveraging AI and technology for enhanced accuracy and efficiency in provider payment processes.

... read more

Drew Satriano

Vice President of Payment Integrity
Highmark Health

Drew Satriano, a seasoned professional with an MBA, CPA, CFE, and JD, brings extensive expertise in payment integrity, accounting, auditing, and legal matters within regulated environments. Notably, he has spearheaded innovative initiatives resulting in a 968% increase in savings since 2014. His recent focus includes leveraging AI and technology for enhanced accuracy and efficiency in provider payment processes.

  1. Gain a comprehensive understanding of payment integrity functions and the initial steps required to establish a payment integrity team.
  2. Learn about vendor setup and staffing strategies essential for building a successful payment integrity function.
  3. Understand the fundamentals of payment integrity 
Track 2: Developing Payment Integrity Function

Author:

Monique Pierce

Payment Solutions & Operations
Cohere Health

Monique is a Strategic Executive Healthcare Leader with proven ability to develop solutions and maximize the benefits of Payment Integrity programs.  She is known for having excellent domain knowledge and being driven, high performing, and having a deep dedication to recruiting and developing top talent.

 

Monique started her Payment Integrity career at Oxford HealthPlans in the COB and Subrogation Department after spending time in Payment Policy.  When United Healthcare acquired many health plans in the early 2000s like Oxford, Monique was tagged as part of the Optum team to integrate the processes and people into the COB systems that she had built at Oxford.  She led systems development, quality, reporting, operations, vendor management and was responsible for creating innovative proactive programs that more than doubled savings to $1.4B in three years.

 

Monique developed a successful program that reduced interest expense on late claims for UHC, assisted a communication company to develop COB tools and assisted in strategic system projects before joining SCIO Health Analytics in 2014 to develop new products - specifically prepayment programs.

In 2015 she became the product owner of SCIOMine, the company’s internal audit application and managed the roadmap.  Monique also owned

strategic direction for operational metrics and reporting including executive scorecards. Monique was promoted to VP of Business Opportunities and Client Engagement where she improved Audit Recovery TAT by 39% and reduced client implementations TAT by 11% and the Level of Effort by 18% while increasing the count of implementation projects by 126%.

 

In 2020 Monique joined Devoted Health, a startup company with the goal of building the first ever integrated Payment Integrity Program.  The company has one system, great data, and a great mission; to change health care by treating every member as if they are family.

 

In her spare time, Monique volunteers her time in the community on the Board of Directors of SCARE NH and works in her family business LARP Portal with her husband Rick.

... read more

Monique Pierce

Payment Solutions & Operations
Cohere Health

Monique is a Strategic Executive Healthcare Leader with proven ability to develop solutions and maximize the benefits of Payment Integrity programs.  She is known for having excellent domain knowledge and being driven, high performing, and having a deep dedication to recruiting and developing top talent.

 

Monique started her Payment Integrity career at Oxford HealthPlans in the COB and Subrogation Department after spending time in Payment Policy.  When United Healthcare acquired many health plans in the early 2000s like Oxford, Monique was tagged as part of the Optum team to integrate the processes and people into the COB systems that she had built at Oxford.  She led systems development, quality, reporting, operations, vendor management and was responsible for creating innovative proactive programs that more than doubled savings to $1.4B in three years.

 

Monique developed a successful program that reduced interest expense on late claims for UHC, assisted a communication company to develop COB tools and assisted in strategic system projects before joining SCIO Health Analytics in 2014 to develop new products - specifically prepayment programs.

In 2015 she became the product owner of SCIOMine, the company’s internal audit application and managed the roadmap.  Monique also owned

strategic direction for operational metrics and reporting including executive scorecards. Monique was promoted to VP of Business Opportunities and Client Engagement where she improved Audit Recovery TAT by 39% and reduced client implementations TAT by 11% and the Level of Effort by 18% while increasing the count of implementation projects by 126%.

 

In 2020 Monique joined Devoted Health, a startup company with the goal of building the first ever integrated Payment Integrity Program.  The company has one system, great data, and a great mission; to change health care by treating every member as if they are family.

 

In her spare time, Monique volunteers her time in the community on the Board of Directors of SCARE NH and works in her family business LARP Portal with her husband Rick.

Author:

Danielle Nelson

FWA Program Manager
PacificSource Health Plan

Danielle M. Nelson graduated from the University of Missouri with a Bachelor of Science in Criminology and Criminal Justice. In 2017, she received a Master of Arts in Management and Leadership from Webster University.

Prior to joining for PacificSource Health Plans (PacificSource) as the Fraud, Waste and Abuse Program Manager in 2022, Ms. Nelson spent seven years working in Special Investigations Units (SIU) of varying sizes at both for-profit and not-for profit organizations, allowing her to gain experience in investigating fraud for government-funded programs, ACA, FEHB, and commercial lines of business. Before moving into fraud investigations in health care, Ms. Nelson spent 15 years in finance, working in consumer lending and back-office operations.

Ms. Nelson is a member of the Association of Certified Fraud Examiners, the St. Louis Chapter of ACFE, and National Health Care Anti-Fraud Association (NHCAA) and a participant with the Healthcare Fraud Prevention Partnership (HFPP).

... read more

Danielle Nelson

FWA Program Manager
PacificSource Health Plan

Danielle M. Nelson graduated from the University of Missouri with a Bachelor of Science in Criminology and Criminal Justice. In 2017, she received a Master of Arts in Management and Leadership from Webster University.

Prior to joining for PacificSource Health Plans (PacificSource) as the Fraud, Waste and Abuse Program Manager in 2022, Ms. Nelson spent seven years working in Special Investigations Units (SIU) of varying sizes at both for-profit and not-for profit organizations, allowing her to gain experience in investigating fraud for government-funded programs, ACA, FEHB, and commercial lines of business. Before moving into fraud investigations in health care, Ms. Nelson spent 15 years in finance, working in consumer lending and back-office operations.

Ms. Nelson is a member of the Association of Certified Fraud Examiners, the St. Louis Chapter of ACFE, and National Health Care Anti-Fraud Association (NHCAA) and a participant with the Healthcare Fraud Prevention Partnership (HFPP).

 

Danielle Nelson

FWA Program Manager
PacificSource Health Plan

Danielle M. Nelson graduated from the University of Missouri with a Bachelor of Science in Criminology and Criminal Justice. In 2017, she received a Master of Arts in Management and Leadership from Webster University.

Read full bio

Danielle Nelson

FWA Program Manager
PacificSource Health Plan

Danielle Nelson

FWA Program Manager
PacificSource Health Plan

Danielle M. Nelson graduated from the University of Missouri with a Bachelor of Science in Criminology and Criminal Justice. In 2017, she received a Master of Arts in Management and Leadership from Webster University.

Prior to joining for PacificSource Health Plans (PacificSource) as the Fraud, Waste and Abuse Program Manager in 2022, Ms. Nelson spent seven years working in Special Investigations Units (SIU) of varying sizes at both for-profit and not-for profit organizations, allowing her to gain experience in investigating fraud for government-funded programs, ACA, FEHB, and commercial lines of business. Before moving into fraud investigations in health care, Ms. Nelson spent 15 years in finance, working in consumer lending and back-office operations.

Ms. Nelson is a member of the Association of Certified Fraud Examiners, the St. Louis Chapter of ACFE, and National Health Care Anti-Fraud Association (NHCAA) and a participant with the Healthcare Fraud Prevention Partnership (HFPP).