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  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.

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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.

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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.

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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 started her Payment Integrity career in COB at Oxford HealthPlans.  After the merger with UnitedHealthcare, she led multiple teams and was responsible for creating innovative programs. Monique joined SCIO Health Analytics in 2014 and was responsible for system and process improvements before being promoted to VP of client engagement and business optimization   In 2020, Monique joined start-up Devoted Health and created a full suite of programs from the ground up.   Based on a passion for metrics and measuring performance, she centralized and standardized all programs reducing implementation time and maximizing savings.   Today, Monique is driving opportunities to improve claim payment by designing and developing new prior auth and claim reconciliation products at Cohere Health.  

... read more

Monique Pierce

Payment Solutions & Operations
Cohere Health

Monique started her Payment Integrity career in COB at Oxford HealthPlans.  After the merger with UnitedHealthcare, she led multiple teams and was responsible for creating innovative programs. Monique joined SCIO Health Analytics in 2014 and was responsible for system and process improvements before being promoted to VP of client engagement and business optimization   In 2020, Monique joined start-up Devoted Health and created a full suite of programs from the ground up.   Based on a passion for metrics and measuring performance, she centralized and standardized all programs reducing implementation time and maximizing savings.   Today, Monique is driving opportunities to improve claim payment by designing and developing new prior auth and claim reconciliation products at Cohere Health.  

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).

Learn how one health plan worked to implement both primary care capitation and global capitation in their market.  The healthplan will explain how they leveraged their provider relationships to develop capitation models, configured their systems to pay capitation and were able to deepen the collaboration with providers.

1. Learn how to leverage your system capabilities and data to implement capitation.

2. Explore better strategies to collaborate with providers implementing payment change.

3. Understand how to measure success under a capitated contract.

Track 1: Advanced Payment Integrity Function

Author:

Cathy Newman

Managing Director Value-Based Strategy
Blue Cross Blue Shield of Rhode Island

Cathy Newman is the Managing Director of Value-Based strategy for Blue Cross Blue Shield of Rhode Island.  Her experience in the healthcare industry spans over twenty years working for both large integrated providers, small IPAs, and health plans.  In her ten years with Blue Cross, she has worked to advance value-based opportunities from pay for performance to full-risk global capitation models.  She is passionate about her work and has been able to develop more collaborative and meaningful relationships with providers throughout the state of Rhode Island.

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Cathy Newman

Managing Director Value-Based Strategy
Blue Cross Blue Shield of Rhode Island

Cathy Newman is the Managing Director of Value-Based strategy for Blue Cross Blue Shield of Rhode Island.  Her experience in the healthcare industry spans over twenty years working for both large integrated providers, small IPAs, and health plans.  In her ten years with Blue Cross, she has worked to advance value-based opportunities from pay for performance to full-risk global capitation models.  She is passionate about her work and has been able to develop more collaborative and meaningful relationships with providers throughout the state of Rhode Island.

  1. Understand the role of payers, providers, CMS, and PBMs in effectively combatting pharmacy fraud.
  2. Learn strategies for identifying fraudulent prescriptions and reducing waste through collaborative efforts.
  3. Explore ways to establish effective communication networks between these groups to prevent duplicate claims.

Author:

Michael Devine

Director Special Investigations Unit
L.A Care
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Michael Devine

Director Special Investigations Unit
L.A Care