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Discover how health plans can strategically embrace insourcing through Software-as-a-Service, regaining control of payment integrity reviews with an AI-driven platform. Join this breakout session to learn how Apixio supports teams at various readiness stages, developing configurable insourcing programs. Providing flexibility, our configurable SaaS platform is designed to meet health plans where they are in their payment integrity journey.

Author:

Brad Ross

EVP, Payment Integrity
Apixio
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Brad Ross

EVP, Payment Integrity
Apixio

Author:

Amy Anzola, RN, MSN

VP, Clinical Operations
Apixio
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Amy Anzola, RN, MSN

VP, Clinical Operations
Apixio

Innovative approaches to provider education, change in billing behaviour, and reduction in medical cost of care.

Author:

David V. Cardelle, R.Ph.

Chief Strategy Officer, SVP, Health Plan Strategy & Partnerships
Advanced Medical Strategies
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David V. Cardelle, R.Ph.

Chief Strategy Officer, SVP, Health Plan Strategy & Partnerships
Advanced Medical Strategies

Alan Coulter will explain the history of how the payment integrity and revenue cycle issues with Coordination of Benefits began, provide examples of current problems, and what downstream impacts can occur if COB issues are not addressed at the member, group, and claims level for both payers and providers. He will also provide some tips for healthcare insurance companies wishing to maximize their processes to assist their provider partners and vice versa when caring for patients with multiple coverages.

Author:

Alan Coulter

VP of Business Development
Performant
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Alan Coulter

VP of Business Development
Performant

While surgical implants are designed to be discreet and invisible for patients, for payers, implant costs can have a very noticeable impact on spending. Many health plans overpay for surgical implants due to lack of true cost transparency, national price variations, and incorrect billing for non-implantable items. The amount paid by health plans is often significantly higher than the provider’s true acquisition cost, equating to markups of 1,000% or more at times.

While off-the-shelf bill review solutions identify some savings, not all solutions are created equal. Comprehensive programs where the bill review process is managed end-to-end by industry experts and that are backed by the most up-to-date facility-specific implant cost data have been independently validated to deliver consistently greater savings.

Join this roundtable discussion to learn best practices for managing your surgical implant costs. We will cover what to look for when selecting a payment integrity partner to generate maximum cost savings, how to ensure durable and defensible savings that hold up through reconsiderations, and Paradigm’s industry-leading results. 

The roundtable will be hosted by Matt Ruyter, Senior Director of Product from Paradigm. Paradigm has reviewed over $2.3 billion in total implant charges, resulting in hundreds of millions of dollars of savings for our clients.

Author:

Matt Ruyter

Senior Director of Product
Paradigm
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Matt Ruyter

Senior Director of Product
Paradigm
  • Highlights on DRG processes and procedures for success 
  • KPIs, and Client Concerns 
  • AI - A DRG Game-changer? 
  • Case studies on DRG audits
Track 2

Author:

Katreece Baker,

VP of Clinical Operations
DRG Claims Management
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Katreece Baker,

VP of Clinical Operations
DRG Claims Management

Author:

Tom Martin

PI Consultant
Independent
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Tom Martin

PI Consultant
Independent

Learn how health plans can realize cost avoidance savings of $4.00-$7.00 PMPY (per member per year), by adopting proactive AI-based provider education, including a provider self-monitoring portal. For a mid-size health plan with 500k members, $2M-$3.5M in cost avoidance could be realized annually. As the payment integrity industry continues to ‘shift left’ through pre-claim submission efforts, it seeks AI-driven tools to maximize coding accuracy and increase savings. Health plans can benefit from automation to address resource constraints, identification of previously undetectable emerging coding issues, and collaboration and trust with their provider network. Join us to hear about our health plan partner journeys to pre-pay cost avoidance without provider abrasion. 

Track 1

Author:

Jesse Montgomery

VP of Analytics and Data Science
Codoxo
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Jesse Montgomery

VP of Analytics and Data Science
Codoxo

Author:

Rena Bielinski

VP Customer Success
Codoxo
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Rena Bielinski

VP Customer Success
Codoxo
Track 1

Author:

Lawrence M. Simon, MD, MBA, FACS

Interim Senior Medical Director
Blue Cross and Blue Shield of Louisiana (BCBSLA)

Dr. Larry Simon is the Interim Senior Medical Director and Managing Medical Director for Medical Policy and Medical Appeals for Blue Cross and Blue Shield of Louisiana (BCBSLA), where he also serves as the Medical Director for Coding and Reimbursement and Chair of the Credentialing and Medical Quality Management Committees.  He is a member of the AMA CPT Editorial Panel, serving on the Executive Committee and as Co-Chair of the Molecular Pathology Advisory Group and Genomic Sequencing Procedures Workgroup.  He also chairs the Medical Director’s Forum for both the Louisiana Association of Health Plans and the National Anti-Fraud Advisory Board of the Blue Cross and Blue Shield Association.  Prior to joining BCBSLA, Dr. Simon served in numerous leadership roles for the American Academy of Otolaryngology, the American Medical Association, the American College of Surgeons, and the Louisiana State Medical Society. 

Dr. Simon is an alumnus of Louisiana State University, Baylor College of Medicine, Rady Children’s Hospital, and the BI Moody College of Business Administration at the University of Louisiana.  A diplomate of the American Board of Otolaryngology and a Fellow of the American College of Surgeons, Dr. Simon has over 15 years of experience in Health Policy and Healthcare Reform, and he has presented over 170 lectures and seminars on these topics. 

A Rotarian, an animal rescuer, a member of multiple civic boards, and a patron of the arts, Dr. Simon enjoys spending his time outside of work serving his community, helping the animal shelters and abandoned dogs of Louisiana, and travelling and enjoying life with his wife and their family and friends.

... read more

Lawrence M. Simon, MD, MBA, FACS

Interim Senior Medical Director
Blue Cross and Blue Shield of Louisiana (BCBSLA)

Dr. Larry Simon is the Interim Senior Medical Director and Managing Medical Director for Medical Policy and Medical Appeals for Blue Cross and Blue Shield of Louisiana (BCBSLA), where he also serves as the Medical Director for Coding and Reimbursement and Chair of the Credentialing and Medical Quality Management Committees.  He is a member of the AMA CPT Editorial Panel, serving on the Executive Committee and as Co-Chair of the Molecular Pathology Advisory Group and Genomic Sequencing Procedures Workgroup.  He also chairs the Medical Director’s Forum for both the Louisiana Association of Health Plans and the National Anti-Fraud Advisory Board of the Blue Cross and Blue Shield Association.  Prior to joining BCBSLA, Dr. Simon served in numerous leadership roles for the American Academy of Otolaryngology, the American Medical Association, the American College of Surgeons, and the Louisiana State Medical Society. 

Dr. Simon is an alumnus of Louisiana State University, Baylor College of Medicine, Rady Children’s Hospital, and the BI Moody College of Business Administration at the University of Louisiana.  A diplomate of the American Board of Otolaryngology and a Fellow of the American College of Surgeons, Dr. Simon has over 15 years of experience in Health Policy and Healthcare Reform, and he has presented over 170 lectures and seminars on these topics. 

A Rotarian, an animal rescuer, a member of multiple civic boards, and a patron of the arts, Dr. Simon enjoys spending his time outside of work serving his community, helping the animal shelters and abandoned dogs of Louisiana, and travelling and enjoying life with his wife and their family and friends.